Carly Graf, Author at ��ýҕ�l Health News

‘Conscience’ Bills Let Medical Providers Opt Out of Providing a Wide Range of Care

Carly Graf — Thu, 03 Aug 2023 09:00:00 +0000

A new Montana law will provide sweeping legal protections to health care practitioners who refuse to prescribe marijuana or participate in procedures and treatments such as abortion, medically assisted death, gender-affirming care, or others that run afoul of their ethical, moral, or religious beliefs or principles.

The law, which goes into effect in October, will to take legal action if they believe they didn’t receive proper care due to a conscientious objection by a provider or an institution, such as a hospital.

So-called medical conscience objection laws have existed at the state and federal levels for years, with most protecting providers who refuse to perform an abortion or sterilization procedure. But the new Montana law, and others like it that have passed or been introduced in statehouses across the U.S., goes further, to the point of undermining patient care and threatening the right of people to receive lifesaving and essential care, according to critics.

“I tend to call them ‘medical refusal bills,’” said Liz Reiner Platt, the director of Columbia Law School’s . “Patients are being denied the standard of care, being denied adequate medical care, because objections to certain routine medical practices are being prioritized over patient health.”

This year, 21 bills instituting or expanding conscience clauses have in statehouses, and two have become law, according to the nonprofit Guttmacher Institute. Florida lawmakers passed legislation that allows providers and insurers to refuse any health service that violates ethical beliefs. Montana’s law goes further, prohibiting the assignment of health workers to provide, facilitate, or refer patients for abortions unless the providers have consented in writing. South Carolina, Ohio, and Arkansas previously passed bills.

Supporters of the Montana law, called the Implement Medical Ethics and Diversity Act, say it fills gaps in federal law, empowering more medical professionals to practice medicine based on their conscience in circumstances beyond abortion and sterilization.

The bill applies to a wide range of practitioners, institutions, and insurers, encompassing just about any type of health care and anyone who could be providing it. The exception is emergency rooms, where the federal takes precedence.

“We have technology that is pushing the limits of what is maybe ethical, and that is different in everybody’s minds,” said Republican state Rep. Amy Regier, who sponsored the Montana bill. “Having extra protections for people to practice according to their conscience as we continue down that path of innovation is important.”

Claims the bill discriminates against patients frustrate Regier, who said it’s about protecting health care providers. “Because someone has a conscientious objection to a specific service, they should be able to practice that way,” she said.

In 1973, federal regulations known as the Church Amendments were implemented after the Supreme Court’s Roe v. Wade decision made abortion legal nationwide. Under the Church Amendments, any institution that receives funding from the federal Department of Health and Human Services may not require health care providers to perform abortion or sterilization procedures if doing so would violate their religious or moral principles. Additionally, providers who refuse to perform these services may not be discriminated against for their decision.

Since then, at least 45 states have abortion conscience clauses, according to the Guttmacher Institute. Of those, that patients be notified of the refusal or limit the clause’s use in the case of miscarriage or emergency.

A in the American Medical Association’s Journal of Ethics said, “Clinicians who object to providing care on the basis of ‘conscience’ have never been more robustly protected than today.” Legal remedies for patients who receive inadequate care as a result have shrunk significantly, the article said.

But the wave of medical conscience bills introduced in statehouses since that article was published go beyond abortion to include contraception, sterilization, gender-affirming care, and other services. Opponents such as the American Civil Liberties Union, Planned Parenthood, and the Human Rights Campaign have been vocal opponents of this trend, criticizing it as a backdoor way to restrict the rights of women, LGBTQ+ community members, and other individuals.

Still, lawmakers across the country insist the right of doctors, nurses, pharmacists, and other medical providers to practice medicine in alignment with their beliefs is being infringed.

Some health care practitioners would “just be done” practicing medicine if forced to perform certain procedures such as abortion, Regier said. “That, to me, is what limits patient care.”

Many of the most sweeping bills are backed by organizations that have made it their business to promote this “conscience” agenda nationwide, such as the Christian Medical Association, Catholic Medical Association, and National Association of Pro-Life Nurses. Other groups launched a joint effort in 2020 with the of advancing state legislation that makes it easier for health care providers to refuse to perform a wide range of procedures, including abortion and types of gender-affirming care.

The organizations that started the initiative are the Religious Freedom Institute in Washington D.C., an Arizona-based nonprofit called the , and the Christ Medicus Foundation in Michigan. According to its website, the coalition bolsters efforts to pass more sweeping medical conscience legislation, using methods including print and digital media campaign strategy, grassroots organizing, and advocacy. After successes in Arkansas, Ohio, and South Carolina in 2021 and 2022, it turned to Montana and Florida. Regier said there are a “number of different organizations” pushing this type of legislation, including the Alliance Defending Freedom.

Most of these conscience laws are part of an “arsenal” to further social conservatism, and they are often religiously motivated, said Lori Freedman, a researcher and associate professor at the Bixby Center for Global Reproductive Health at the University of California-San Francisco.

Although federal law is meant to ensure people receive lifesaving care in an emergency, Freedman said, there are cases in which patients don’t receive the care they should simply because they don’t clear the bar of what a facility considers emergent.

While experts warn of the potential patient health consequences of these medical conscience bills, academics say placing a provider’s choice over their patient’s rights is itself a threat.

“These bills do not protect religious liberty because they make it impossible for people to follow their own religious and moral values in making major decisions,” Reiner Platt said.

About 1 in 6 patients in the U.S. are treated in Catholic health care facilities, according to Freedman. Many of those venues strictly regulate or prohibit certain procedures, such as abortion, but do not necessarily disclose that to patients. As of 2016, of hospital beds in Montana were in such facilities, according to the ACLU. Freedman determined through her research that about one-third of people whose primary hospital was Catholic didn’t know of its religious affiliation and therefore were unaware of those limitations on their care.

The problem can extend to secular medical institutions, too. According to the AMA Journal of Ethics article, there are no rules requiring a patient be informed a provider is practicing conscientious objection, which means the patient might “unknowingly receive substandard care” and “even be harmed by” the provider’s refusals.

“As much as we like to think about these providers and their opinions, so much is determined at a larger, structural level,” Freedman said. “Abortion has been stigmatized, marginalized, and constrained,” and plenty of hospitals and physician groups have made great efforts to “make a very safe service somehow illegal to provide within their context.”

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Fresh Produce Is an Increasingly Popular Prescription for Chronically Ill Patients

Carly Graf — Thu, 23 Mar 2023 09:00:00 +0000

When Mackenzie Sachs, a registered dietitian on the Blackfeet Reservation, in northwestern Montana, sees a patient experiencing high blood pressure, diabetes, or another chronic illness, her first thought isn’t necessarily to recommend medication.

Rather, if the patient doesn’t have easy access to fruit and vegetables, she’ll enroll the person in the FAST Blackfeet produce prescription program. FAST, which stands for Food Access and Sustainability Team, provides vouchers to people who are ill or have insecure food access to reduce their cost for healthy foods. Since 2021, Sachs has recommended a fruit-and-vegetable treatment plan to 84 patients. Increased consumption of vitamins, fiber, and minerals has improved those patients’ health, she said.

“The vouchers help me feel confident that the patients will be able to buy the foods I’m recommending they eat,” she said. “I know other dietitians don’t have that assurance.”

Sachs is one of a growing number of health providers across Montana who now have the option to write a different kind of prescription — not for pills, but for produce.

The Montana Produce Prescription Collaborative, or MTPRx, brings together several nonprofits and health care providers across Montana. Led by the , the initiative was recently awarded a federal grant of $500,000 to support Montana produce prescription programs throughout the state over the next three years, with the goal of reaching more than 200 people across 14 counties in the first year.

Participating partners screen patients for chronic health conditions and food access. Eligible patients receive prescriptions in the form of vouchers or coupons for fresh fruits and vegetables that can be redeemed at farmers markets, food banks, and stores. During the winter months, when many farmers markets close, MTPRx partners rely more heavily on stores, food banks, and nonprofit food organizations to get fruits and vegetables to patients.

The irony is that rural areas, where food is often grown, can also be food deserts for their residents. , a researcher and clinical instructor with , said produce prescription programs in rural areas are less likely than others to have reliable access to produce through grocers or other retailers. A concluded 91% of the counties nationwide whose residents have the most difficulty accessing adequate and nutritious food are rural.

“Diet-related chronic illness is really an epidemic in the United States,” Garfield said. “Those high rates of chronic conditions are associated with huge human and economic costs. The idea of being able to bend the curve of diet-related chronic disease needs to be at the forefront of health care policy right now.”

An example of a voucher for fresh produce distributed by the FAST Blackfeet produce prescription program. FAST, which stands for Food Access and Sustainability Team, provides vouchers to people who are ill or have insecure food access on the Blackfeet reservation.

Produce prescription programs have been around , when opened a clinic in Mound Bayou, a small city in the Mississippi Delta. There, Dr. Geiger saw the need for “social medicine” to treat the chronic health conditions he saw, many the result of poverty. He prescribed food to families with malnourished children and paid for it out of the clinic’s pharmacy budget.

by the consulting firm DAISA Enterprises identified 108 produce prescription programs in the U.S., all partnered with health care facilities, that launched between 2010 and 2020, with 30% in the Northeast and 28% in the Midwest. Early results show the promise of integrating produce into a clinician-guided treatment plan, but the viability of the approach is less proven in rural communities such as many of those in Montana.

In Montana, 31,000 children do not have consistent access to food, the Montana Food Bank Network. Half of the state’s 56 counties are considered food deserts, where low-income residents must travel more than 10 miles to the nearest supermarket — which is the U.S Department of Agriculture uses for low food access in a rural area.

Research shows long travel distances and lack of transportation are significant barriers to accessing healthy food.

“Living in an agriculturally rich community, it’s easy to assume everyone has access,” said Gretchen Boyer, executive director of . The organization works with nearby health care system Logan Health to provide more than 100 people with regular produce allotments.

“Food and nutritional insecurity are rampant everywhere, and if you grow up in generational poverty you probably haven’t had access to fruits and vegetables at a regular rate your whole life,” Boyer said.

More than 9% of Montana adults have Type 2 diabetes and nearly 35% are pre-diabetic, according to Merry Hutton, regional director of community health investment for Providence, a health care provider that operates clinics throughout western Montana and is one of the MTPRx clinical partners.

Brittany Coburn, a family nurse practitioner at Logan Health, sees these conditions often in the population she serves, but she believes produce prescriptions have tremendous capacity to improve patients’ health.

“Real food matters and increasing fruits and veggies can reverse some forms of diabetes, eliminate elevated cholesterol, and impact blood pressure in a positive way,” she said.

Mackenzie Sachs, a registered dietitian, and Thedra Bird Rattler, a nutrition education specialist, work for FAST Blackfeet.

Produce prescription programs have the potential to reduce the costs of treating chronic health conditions that overburden the broader health care system.

“If we treat food as part of health care treatment and prevention plans, we are going to get improved outcomes and reduced health care costs,” Garfield said. “If diet is driving health outcomes in the United States, then diet needs to be a centerpiece of health policy moving forward. Otherwise, it’s a missed opportunity.”

The question is, Do food prescription initiatives work? They typically lack the funding needed to foster long-term, sustainable change, and they often fail to track data that shows the relationship between increased produce consumption and improved health, according to a on such programs.

Data collection is key for MTPRx, and partners and health care providers track how participation in the program influences participants’ essential health indicators such as blood sugar, lipids, and cholesterol, organizers said.

“We really want to see these results and use them to make this more of a norm,” said Bridget McDonald, the MTPRx program director at CFAC. “We want to make the ‘food is medicine’ movement mainstream.”

Sachs acknowledged that “some conditions can’t usually be reversed,” which means some patients may need medication too.

However, MTPRx partners hope to make the case that produce prescriptions should be considered a viable clinical intervention on a larger scale.

“Together, we may be able to advocate for funding and policy change,” Sachs said.

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Montana’s New Sex Ed Law Ensnares English and History Lessons, Too

Carly Graf — Thu, 01 Dec 2022 10:00:00 +0000

A Montana law requiring public schools to notify parents of lessons that mention human sexuality — and allowing parents to pull their children from those lessons — has reached further and been more cumbersome than anticipated, according to two school district leaders.

School districts across the state consulting with attorneys and retooling their policies to ensure they are in compliance with the law passed in 2021. requires parents to be notified at least 48 hours in advance about lessons related to sexual education, as well as other topics, including anatomy, intimate relationships, sexual orientation, gender identity, contraception, and reproductive rights.

Because of the law’s broad scope, some schools have decided to notify parents about topics that may not be obviously related to human sexuality. In Billings, for example, school administrators of high school students at the beginning of the school year that flagged literary works such as “The Great Gatsby” and “Romeo and Juliet” because they describe intimate relationships. History and U.S. government lessons involving civil rights and certain U.S. Supreme Court cases are on the list. So, too, are biology classes that involve sexual reproduction — even nonhuman reproduction.

“Frankly, it’s a pain to have to send out notices to parents of students in courses like biology where there may be a lesson taught on genetics because the lesson mentions testes, ovaries, sperm, egg, fertilization, etc.,” said Micah Hill, superintendent of the Kalispell school district.

State Sen. Cary Smith (R-Billings), who sponsored the bill, did not respond to requests for comment on how the law was affecting schools. Before the state Senate voted on the bill in 2021, Smith said the law was needed because today’s comprehensive sexual education encompasses much more than just biology and anatomy.

“This type of sex education deals with a lot of other issues, such as feelings, what’s normal, what isn’t normal, and a lot of times those teachings conflict with what we try to teach our children at home and in our churches,” he said.

The Kalispell school district determined that the law applied to health classes; science lessons that involve anatomy, genetics, or reproduction; advanced psychology courses whose curriculum includes human development; certain social sciences classes; and many more.

“There really is no end to what might be considered given the broad definition that came out of the state legislature,” Hill said.

Hill said that Kalispell schools and teachers send the notifications and that he did not have the number sent so far this school year. “I don’t track where teachers are at in their curriculum pacing, so if it hasn’t happened, it is probably a matter of time,” he said.

No school district has announced changes to their curricula as a result of SB 99. Local school boards generally set school curricula through a public process in which community members are invited to offer feedback. Schools also rely heavily on the set by the statewide education agency, the Montana Office of Public Instruction.

Also in response to SB 99, schools are consulting with attorneys and combing through material for any mention of the topics that fall under the law’s definition of human sexuality.

Teachers must not only work with administrators and legal teams to determine which lessons might trigger notification under SB 99 but must also be careful that classroom discussions don’t stray into areas that require notification if none has been given.

“On the teacher side of this, it feels like an unnecessary layer of bureaucracy and overreach by the state to insert itself into locally controlled and elected school boards,” Hill said.

Smith said during the 2021 debate that the measure does not tell schools what they can teach. “We’re just telling them to let us know as parents and grandparents what is being taught so we can decide if we want our children to participate in those courses,” he said.

Missoula County Public Schools Interim Superintendent Russ Lodge said the district has sent parental notifications since the beginning of the school year. But he could not say how many or provide examples because he is not directly involved in the individual schools’ process. He said he wants his district, like Billings, to eventually include all subject matter that falls under SB 99’s notification requirement in a district-wide letter sent out every August.

“Whoever wrote it obviously broadened the definition out on purpose, and it covers a lot of ground,” he said.

Aside from the law’s effects on seemingly tangential subjects, critics said SB 99 threatens to stifle important classroom discussions on sexual health, gender identity, and personal development. Critics also said it could reduce the number of students who learn about contraception — knowledge that has to help reduce rates of teen pregnancy — and about LGBTQ+ rights. The law could also discourage teachers from including certain subjects in their lessons or hinder their ability to respond freely to questions or comments from students, the critics said.

Montana’s education department “reflect the values of the community” and be abstinence-based and age-appropriate.

Pamela Kohler, an associate professor of global health at the University of Washington, said that “overwhelmingly shows that abstinence-only education is not effective at preventing sexual activity or pregnancy” and that “many of those at highest risk for unwanted pregnancy and STDs receive no or inadequate sex education.”

More than 40% of Montana high schoolers have had sex, according to the 2021 , and just under half of them are not using condoms regularly, which raises their risk of becoming pregnant and developing sexually transmitted diseases. found that more than 80% of students did not know basic information about HIV transmission and prevention.

Failing to teach about gender identity, sexual health, intimacy, and other elements of human sexuality means young people may have trouble finding accurate information, said Michelle Slaybaugh, director of social impact and strategic communications for SIECUS, an organization that advocates for comprehensive sexual education. And it makes students grappling with their sexual or gender identity more vulnerable, Slaybaugh added.

“Relationships and sexuality education has been proven to keep young people safer from bullying, help manage their feelings, concentrate in school, and develop the long-lasting skills they need to have healthy, strong relationships,” Slaybaugh said.

SB 99 also prohibits people who work at a clinic or organization that provides abortions from speaking or teaching at schools across the state, even if their lesson has nothing to do with abortion. That stipulation may have led to the termination of at least one long-standing relationship between a school district and a provider.

Bridgercare, a nonprofit reproductive health organization based in Bozeman that this year beat out the state health department for family planning, had partnered with Bozeman Public Schools for 25 years to provide comprehensive sexual education to students. The organization, which does not provide abortions, has not been invited to provide instruction to Bozeman campuses this school year, according to Bridgercare officials.

The Bozeman school district’s superintendent, Casey Bertram, declined to be interviewed about the law and Bridgercare’s ties to the district.

“Whether parents like it or not, teens are navigating the challenges of adolescence and all of the emotional challenges that can bring,” said Cami Armijo-Grover, Bridgercare’s education director. “The best thing we can do for our kids is to educate them on how their bodies work and give them tools to navigate the feelings and challenges that come with puberty and relationships.”

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Policies to Roll Back Abortion Rights Will Hit Incarcerated People Particularly Hard

Carly Graf — Mon, 22 Aug 2022 09:00:00 +0000

[UPDATED on Sept. 7]

Policies governing abortion and reproductive health care services in U.S. prisons and jails were restrictive and often hostile even before the for abortions. After the June ruling, many reproductive services stand to be prohibited altogether, putting the health of incarcerated women who are pregnant at risk.

That threat is particularly urgent in states where lawmakers have made clear their intentions to roll back abortion rights.

“Previously there was at least some sliver of legal recourse there for an incarcerated person, but that no longer exists for people who live in states where abortion is or will be severely restricted or illegal,” said Dr. , an OB-GYN, a professor, and the director of the Advocacy and Research on Reproductive Wellness of Incarcerated People program at Johns Hopkins University.

The Northern Rockies and Upper Midwest regions are home to some of the states with the highest rates of incarcerated women in the country. , Idaho has the highest incarceration rate — 110 women per 100,000 adult female residents — of any state, closely followed by South Dakota, Wyoming, and Montana, whose rates are more than double the national average.

Nationally, women make up an increasingly large share of prison and jail populations. From 1980 to 2020, the number of incarcerated women .

State and federal prisons do not reliably track or report the number of incarcerated people who are pregnant. , a nonprofit research organization, estimates about 58,000 people a year are pregnant when they enter prisons or jails, or about 4% of the total number of women in state and federal prisons and 3% of those in local jails.

The quality of pregnancy care available to the incarcerated population varies greatly, not just by state but among facilities, too. That’s due to a lack of universal standards and a range of approaches by authorities governing jails and prisons, as well as the different health care provided, said , deputy director of the ACLU Reproductive Freedom Project. “There is far too little space for accountability, and far too much space for discretion.”

Sufrin co-authored a that surveyed pregnancy outcomes across 22 state prison systems, all federal Bureau of Prisons sites, and six county jails. It concluded that only half the state prisons surveyed allowed abortion in the first and second trimesters, and 14% prohibited it entirely.

Other facilities — including some within the federal Bureau of Prisons, which nominally requires access to abortion and appropriate prenatal and postnatal care during pregnancy — often were found to make abortion and maternal health care services practically inaccessible.

Those with written policies had barriers including distance from abortion care providers, delays in treatment until abortion was no longer legal, and requirements for the pregnant person to pay for the cost of the abortion and, sometimes, transportation to and from a clinic, according to academics and advocates. Other facilities didn’t have a formal written policy and instead left the care of an individual up to the discretion of the prison or jail.

Julia Arroyo of Young Women’s Freedom Center, a criminal justice reform advocacy organization, was pregnant while incarcerated. “Reproductive health access is very difficult on the inside,” she said, adding that women are often made to feel as if they are disruptive or difficult simply for seeking treatment.

“When I was pregnant and experiencing jail, I was never once asked what I wanted to do with my pregnancy,” she said.

Sufrin’s research found that prison facilities in states that she characterized as “hostile” to abortion are more likely to make abortion all but impossible to access. Several states — including South Dakota, Wyoming, and Idaho — have already banned most abortions or are in the process of seeking to implement severe restrictions on abortion.

South Dakota’s banning most abortions took effect immediately after the Supreme Court’s June 24 decision.

An abortion ban that was set to take effect in Wyoming on July 27 by a judge makes the procedure illegal except in cases of incest or rape or to protect the life of the mother.

Idaho’s trigger ban, which is but is also being challenged in court, would prohibit abortion after six weeks of pregnancy. It also criminalizes any person who provides such treatment.

Wyoming’s Department of Corrections declined to comment, and Idaho officials did not respond to questions about how their state’s new abortion ban — which is facing challenges in court — would affect incarcerated people. However, experts suspect statewide prohibitions likely would worsen access in prisons and county jails.

In Montana, abortions are protected by a 1999 state Supreme Court ruling that the Montana Constitution’s right-to-privacy provision extends to a person’s medical decisions. Attorney General Austin Knudsen, a Republican, is asking the state’s high court to reverse that ruling, and Republican Gov. Greg Gianforte has said he would consider calling a special session to consider anti-abortion legislation if lawmakers had a plan that would pass court review. The next regular session is in January, and to .

Montana Department of Corrections spokesperson Alexandria Klapmeier said in an email that all facilities “meet the standards of care for inmates as required by law, including for prenatal care, which is at or above the level of care they would receive were they not incarcerated.”

However, Klapmeier declined to comment further on how the Supreme Court’s decision in would influence the agency’s abortion policies or offer specifics on treatment and protocols. As recently as 2019, that the state fails to ensure that incarcerated pregnant people have access to routine prenatal care.

Federal Bureau of Prisons facilities must provide access to abortion, as well as other reproductive health care services. However, they are not required to pay for the procedures or the transportation to a clinic, which means many women are priced out of the treatment.

The federal prison system and most states require some form of copayment by inmates for medical services, though California and Illinois reversed their policies, according to . Even states without copayment policies can require inmates to pay for medical costs. Montana state correctional facilities do not require inmate copays, but for costs associated with preexisting conditions and self-inflicted or certain other injuries.

There are no federal prisons in Montana, Wyoming, or Idaho. The nearest in the region include six in Colorado, two in Oregon, and one in Washington, all states that have laws protecting abortion access. The Bureau of Prisons declined to comment on how Dobbs would affect policies.

Sufrin said she feared a “chilling effect” from the Dobbs decision on essential pregnancy care for prisoners. That includes treatment of miscarriages, which many experts note often mirrors abortion protocols. Doctors and other health care providers have raised concerns that without that treatment, women’s lives could be at risk since medical professionals are nervous about how their actions might violate state abortion prohibitions.

Forcing someone to carry a pregnancy to term while incarcerated could result in great trauma to the mother, according to multiple experts, as well as compromise the care of the child. Forcing anyone to carry a pregnancy to full term can make it harder for a person to escape poverty and derail life plans, and a forced pregnancy behind bars has even greater punitive consequences, Kolbi-Molinas said.

Despite federal law prohibiting the use of shackles for pregnant women giving birth in federal prisons, some states — among them Montana, Wyoming, and Idaho — do not have laws that make that practice illegal, and prison officials have been in the past.

Incarcerated women are often forced to give birth without a companion, and once the baby is born, the child is typically taken away immediately and housed with a family member or, when one isn’t available, put into the foster care system.

“It violates all the principles of reproductive justice,” Sufrin said. “They do not have the right to choose to have children and they do not have the right to parent.”

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Senate Deal Raises Hopes for a Reduction in Gun Suicides

Carly Graf — Wed, 22 Jun 2022 09:00:00 +0000

A bipartisan U.S. Senate agreement negotiated after high-profile mass shootings in Texas, New York, and Oklahoma lacks gun access restrictions that advocates say are needed to prevent such attacks. But the deal’s focus on mental health has raised hopes — and doubts — that it will help reduce gun suicides, particularly in rural Western states with wide-open gun laws.

Montana, Wyoming, Alaska, and Idaho highest among states in rates. And despite research that concludes stringent firearm safety laws help curb gun violence, lawmakers in those states have long rejected restrictions that experts say would reverse those decades-long trends.

Conservatives in Congress, mirroring their counterparts in those Republican-led states, are resisting sweeping policies that would restrict access to guns, such as raising the minimum age for purchasing AR-15-style rifles to 21. Proposals to change age limits emerged after guns of that type were used recently in an elementary school shooting in Uvalde, Texas; a grocery store shooting in Buffalo, New York; and a hospital shooting in Tulsa, Oklahoma.

Instead, 10 Republican senators that includes a provision that would help fund red flag laws, which allow courts to temporarily confiscate firearms from people deemed a threat to themselves or others. and Washington, D.C., have such laws. If all 48 Democratic senators and two independents who typically vote with the Democrats are in agreement, that group would be large enough to overcome any filibuster and pass the bill.

The deal also includes enhanced background checks for people younger than 21 and significant investment in mental health and telehealth resources. A was released Tuesday.

But gun control advocates say the deal leaves out measures that have been shown to help prevent suicides — the leading cause of deaths involving guns in the U.S. — such as mandatory waiting periods and safe-storage requirements. They also caution against linking high rates of gun suicide to mental illness.

“It’s important to be really clear that people with mental illness are more likely to be victims of gun violence than perpetrators,” said Sarah Burd-Sharps, senior director of research for the gun control advocacy group Everytown for Gun Safety.

Residents of rural states are particularly vulnerable to gun suicides. a relationship between isolated rural living and “deaths of despair,” those related to substance use, mental health issues, and suicide. Some studies suggest that living at higher altitudes — a reality for many residents of the Mountain West — increases the likelihood that a person will .

Montana had the nationwide in 2019, according to the state health department. From 2010 to 2019, were suicides, compared with . Research overwhelmingly concludes that gun violence.

However, Montana has almost no restrictions on who can buy a gun, what kind of gun a person can purchase, when it can be bought, or how it can be carried in public. The state no longer requires people to obtain a permit to carry a concealed weapon in public places, and lawmakers in Helena passed a law in 2021 that bars universities from regulating firearm possession on campus. That law has been temporarily blocked during a legal challenge.

Wyoming, Alaska, and Idaho similarly have high rates of gun suicide and relatively few restrictions on firearm purchases and possession.

Andrew Rose, a 24-year-old living in Boise, Idaho, knows firsthand how permissive gun laws can have fatal consequences. Rose’s brother killed himself in 2013, using a gun he had purchased the same day.

Rose describes his brother’s suicide as “a moment of crisis,” one that might have passed if Idaho had a mandatory waiting period in place that forced him to pause and consider his plans. Rose believes “the accessibility of guns has everything to do with the suicide rate” and the death of his brother and others like him.

Proposals to restrict gun access in these states are regularly scuttled, so advocacy groups have focused on prevention through mental health care services.

But forcing someone who has a mental illness and is on the cusp of violence into treatment is difficult, said Matt Kuntz, executive director of the Montana chapter of the National Alliance on Mental Illness. “In a state like Montana, where we have so many people who value their gun rights but who also need help, how do you make it as easy as possible?” he said.

Provisions in the U.S. Senate deal are worth exploring, Kuntz said, but any successful federal gun control legislation must be based on state laws that have been tested. “States need to be the laboratories of innovation,” he said.

States with lower gun suicide rates tend to have stricter gun policies. Depending on the state, that for every 10 to 20 firearms removed using a red flag law, also called an extreme risk law, one suicide is prevented.

and Washington, D.C., have some version of a mandatory waiting period, in which there is a delay of three to 14 days for a person to buy a gun. found that waiting periods can reduce gun suicides 7% to 11% and gun homicides 17%.

Waiting periods “create a buffer of time for a person in crisis to think,” Burd-Sharps said. “It can be the difference between someone walking out with a gun and carrying out their plan in a suicidal crisis or reconsidering and saving their life.”

Safe-storage laws, or secure-storage laws, are considered one of the most effective ways to prevent a young person from accessing a gun kept in their household. In firearm owners must keep their guns unloaded, locked, and separated from ammunition. have laws that make firearm owners liable if a child uses their weapon.

But getting enough support for such measures to pass in an evenly divided U.S. Senate would likely be difficult. Even the red flag provision in the agreement came under fire as the framework evolved into legislation, said the lead Republican negotiator, of Texas.

Donald Trump Jr. stoked that opposition , saying, “Any ‘Republican’ selling out to the left to support this trash might as well put a (D) next to their name.”

Sen. Steve Daines, a Montana Republican, he thinks Congress should not “meddle” in states’ decisions about whether to adopt red flag laws.

Republicans aren’t the only lawmakers who have their limits when it comes to gun restrictions. Democrats from rural states are also sensitive to them. Sen. Jon Tester, a Montana Democrat, said measures with broad public support such as stronger background checks and more money for behavioral and mental health services would help combat Montana’s high suicide rate. But Tester that he opposes other measures, such as raising the minimum age to buy semiautomatic rifles.

Advocates for stronger gun laws say robust federal action beyond the current proposal is necessary to create real change.

“I wish everyone understood that if we act together we can make monumental change,” Rose said. “I wish people understood that it is fully within our power to save lives. We simply have to stand up and say the truth.”

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Census Undercount Threatens Federal Food and Health Programs on Reservations

Carly Graf — Thu, 12 May 2022 09:00:00 +0000

The 2020 census missed nearly 1 of every 17 Native Americans who live on reservations, an undercount that could very well lead to insufficient federal funding for essential health, nutrition, and social programs in remote communities with high poverty rates and scarce access to services.

The census counted 9.7 million people who identified as a Native American or an Alaska Native in 2020 — alone or in combination with another race or ethnicity — compared with 5.2 million in 2010. But the Indigenous population on the nation’s approximately was undercounted by nearly 6%, according to of the census’s accuracy. Indigenous people on reservations have a history of being undercounted — nearly 5% were missed in 2010, according to the analysis.

At least 1 in 5 Native Americans live on reservations, . More detailed Native American population data from the 2020 census will be released .

The census numbers help determine how much money is allocated to various programs on reservations such as health care, social services, education, and infrastructure. For example, on the Blackfeet reservation in northwestern Montana, the co-chairperson of a food pantry whose funding is partially dependent upon census counts is worried the undercount will make it more difficult after this year for all the families who need the free meals to access them.

The food pantry — operated by an organization called , which stands for Food Access and Sustainability Team — serves about 400 households a week, said Danielle Antelope. The 2020 census puts the Blackfeet reservation’s population at 9,900, which Antelope said “is not reflecting our numbers to reality.”

lived below the poverty line from 2014 to 2018, compared with a 13% statewide average, according to periodic American Community Survey estimates.

“I see the problem in the undercounting of the census being related to the representation of the need,” Antelope said.

Antelope said she has seen firsthand what it means when people living on reservations slip through the cracks. Her mom was a bus driver who made too much money to be eligible for income-based federal food assistance programs, but not nearly enough to adequately feed her kids. The family depended on processed foods from the frozen aisle.

Where produce is expensive or hard to find, cheap packaged meals are often the only option. “As we know now, those cheap foods relate to health disparities,” Antelope said. “And those health disparities are high in communities of color and tribal communities.”

Census miscounts are not limited to Native Americans on reservations. Black (3%) and Hispanic (5%) people living in the U.S. also were undercounted. Meanwhile, white people were overcounted (2%).

Among U.S. states, Montana has the of Indigenous residents, at 6%, and Native Americans are the state’s second-largest racial or ethnic group, after people who identify as white. The percentage when it includes people who identify as “American Indian and Alaska Native alone or in combination” with another race or ethnicity. Most Indigenous residents live on one of Montana’s seven reservations or in a nearby town or county.

The Indian Health Service, the federal agency obliged to provide medical care to most of the country’s Native residents, receives funding partly based on the census. Nationwide in 2019, the most recent year for which data is available, IHS spent $4,078 per person, . By comparison, Medicaid, the federal health insurance program for people with low incomes and certain disabilities, spent more than twice that rate, . noted that the usefulness of per capita comparisons is limited because the federal programs vary widely.

Health gaps were visible during the pandemic. In Montana, , largely because of other conditions people had, such as respiratory illness, obesity, and diabetes. Heart disease was the second leading cause of death.

More accurate census counts would lead to “more funding support from the federal government and even the state government,” said Leonard Smith, CEO of the Billings-based Native American Development Corp., a nonprofit that provides technical assistance and financial services to small businesses. “I think it makes people realize there’s a much larger Native population than what’s being reported, and so it becomes a higher priority. It’s all about the numbers,” Smith said.

A more accurate count could also help improve infrastructure and housing on reservations.

Federal housing assistance remains inaccessible to many households on tribal reservations. Research points to a strong relationship between housing and better health outcomes. A published in the journal BMC Public Health concluded that almost 70% of people who obtained secure, stable housing reported “significantly better” health situations nine to 12 months later, compared with when they were experiencing housing insecurity.

According to from the National Congress of American Indians, more than 15% of homes in areas on or near Native reservations were considered overcrowded — which means there was more than one person per room, including living rooms, kitchens, bedrooms, and enclosed porches — compared with 2% of homes among other populations.

Although about a quarter of households had incomes below 50% of the federal poverty line, the report said, only about 12% received federal housing assistance. Census data is used to .

“When a census undercounts a Native community, it has a direct and long-reaching impact on the resources that the community receives — things like schools and parks, health care facilities, and roads,” said Michael Campbell, deputy director of the Native American Rights Fund in Boulder, Colorado.

The impact of the undercount on funding transcends budgets and social programs. It creates the feeling among Indigenous people that their presence in this country matters less than that of others, leading to both political disenfranchisement and personal harm, tribal members said.

“Because for so many years we have gotten used to not being counted, we don’t hold that aspiration for our government to create space for us now,” Antelope said. “When we have accurate numbers that reflect our community, our voice is heard, and we can get services and funding that better reflects our community.”

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As Eating Disorders Spike During Pandemic, Rural Treatment Options Lag

Carly Graf — Tue, 19 Apr 2022 09:00:00 +0000

Erin Reynolds had battled bulimia since childhood, but the weeks before she entered treatment were among her worst. At 22, she was preparing to leave her home in Helena, Montana, for an inpatient program in New Jersey with round-the-clock medical care.

Looking back six years later, Reynolds said seeking help was one of the most difficult parts of the recovery process. “I just kept bingeing and purging because I was so stressed,” she said. “I’m leaving my job that I love, leaving all my friends and my town and saying goodbye to normal life.”

Eating disorders, including anorexia, bulimia, and binge-eating disorder, are some of the . Yet treatment options are sparse, particularly in rural states such as Montana.

Emergency department visits for teenage girls dealing with eating disorders doubled nationwide during the pandemic, from the Centers for Disease Control and Prevention. The same report notes that the uptick could be linked to reduced access to mental health services, a hurdle even more acute in rural states.

The provider database shows only two certified providers across all of Montana, the country’s fourth-largest state as measured by square miles. By comparison, Colorado, which is nearly three-quarters of the size of Montana but has five times the population, shows nine providers.

That means many people like Reynolds must leave Montana for treatment, particularly true for those seeking higher levels of care, or drive for hours to attend therapy. It also means more individuals go untreated because they lack the flexibility to give up a paying job or leave loved ones behind.

“A lot of people are not able to access treatment, just given the geography and vast ruralness of the state,” said , a University of Montana assistant professor and psychologist who specializes in eating disorder research.

The most intense treatment involves inpatient or partial hospitalization programs, best for those in need of round-the-clock care and acute medical stabilization. Residential treatment is a step down from there, usually outside a hospital setting at a place akin to a rehab facility.

Once a person in recovery can manage with less hands-on care, a variety of outpatient options may include therapy, meal support, or group counseling. “Finding people with those specialties and availability is often a challenge,” said Lauren Smolar, vice president of mission and education at the eating disorders association.

When Reynolds sought treatment in 2016, not one facility in Montana offered inpatient care, residential treatment, or partial hospitalization. Only one came close: the , a treatment program based in Bozeman and established in 2013.

, who co-founded the center, said there were many barriers to starting an eating disorder treatment facility in Montana, where there were none. There was no licensure process, and challenges abounded, from insurance coverage to the high level of specialization required to provide appropriate care.

The Eating Disorder Center of Montana added a partial hospitalization program in 2017, which provides housing for out-of-towners and requires five to seven days of nearly all-day treatment programming led by a team of experts. The center also plans to open an outpatient therapy facility 200 miles west in Missoula later this year.

A third of people with eating disorders are men, a group that is underdiagnosed and undertreated. Although Black, Indigenous, and other people of color are no less likely to develop an eating disorder, they are to be diagnosed or receive treatment.

a higher rate of eating disorders in urban centers, but it’s difficult to know whether that’s due to reduced stigma and more treatment options in metropolitan areas compared with rural settings.

“We know eating disorder rates are quite high,” Martin-Wagar said. “We’ve been seeing them rise pretty consistently, so this isn’t a niche or specialty issue. It’s something that’s impacting lots and lots of folks.”

The pandemic has made telehealth treatment options more common, which could relieve bottlenecks at treatment facilities. For example, the Eating Disorder Center of Montana is launching virtual outpatient care for any Montana resident this month. , provides telehealth appointments for individual, family, and group therapy. But telehealth treatment for eating disorders is limited in its effectiveness. Many interventions are best in person, such as meal support and helping people establish healthier patterns around eating.

Cost is a barrier to treatment everywhere, but especially in a place like Montana, where about 1 in 5 residents are covered by Medicaid or Healthy Montana Kids, the state’s Children’s Health Insurance Program. It can cost thousands of dollars and take many months for a person to receive adequate care, whether a person is insured or not. And there’s no formula to know how long treatment will take, or how many times a patient will have to move up and down the ladder of levels of care.

Few insurance companies provide meaningful coverage. Their reimbursement might time out after only a few weeks — far sooner than the average course of treatment takes — or not cover it at all.

Martin-Wagar, the University of Montana researcher, said that eating disorder research also receives very little funding relative to other mental health concerns. Without federal and state dollars going directly into treatment and research, eating disorder symptoms can’t be identified early in adolescents, the easiest way to drive down the costs of overall treatment; stigma is harder to combat; and there’s little incentive for new providers to create treatment programs in places outside urban areas with well-documented demand.

“Even if we create more eating disorder centers, if people can’t afford them, then we are only servicing the most privileged in our society,” Martin-Wagar said. “And that means we are not doing a good job.”

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