His monthly premium payment of $435 for family coverage is roughly the same as the insurance at his previous job. But the policy at his current job carries an annual deductible of $4,000, which he must pay out-of-pocket for his family’s care until he reaches that amount each year.

“Now everything is full price,” said the 53-year-old, who works at a warehouse just south of Dallas-Fort Worth. “That’s been a little bit of a struggle.”

To reduce his costs, Garza switched to a lower-cost diabetes medication, and he no longer wears a continuous glucose monitor to check his blood sugar. Since he started his job nearly two years ago, he said, his blood sugar levels have inched upward from an A1c of 7% or less, the target goal, to as high as 14% at his most recent doctor visit in November.

“My A1c is through the roof because I’m not on, technically, the right medication like before,” Garza said. “I’m having to take something that I can afford.”

Plans with high deductibles — the amount that patients must pay for most medical care before insurance starts pitching in — have become increasingly common. In 2024, participating in medical care plans were offered this type of insurance, up from 38% in 2015, according to federal data. Such plans are also offered through the Affordable Care Act marketplace.

With and many of the subsidies to help people pay for them poised to expire at year’s end, more people face tough choices as they weigh monthly premium costs against deductibles. To afford insurance at all, people may opt for a plan with low premium payments but with a high deductible, gambling that they won’t have any medical crises.

But high-deductible plans pose a particular challenge for those with chronic conditions, such as the who live with Type 1 or Type 2 diabetes. Adults with diabetes who are involuntarily switched to a high-deductible plan, compared with adults on other types of insurance, face an 11% higher risk of being hospitalized with a heart attack, a 15% higher risk of hospitalization for a stroke, and that they’ll go blind or develop end-stage kidney disease, according to a study published in 2024.

“All of these complications are preventable,” said , the study’s lead author.

Care vs. Cost

The initial rationale behind such high-deductible plans was to encourage people to become wiser health care shoppers, said McCoy, an associate professor of medicine at the University of Maryland School of Medicine in Baltimore. And they can be a good fit, proponents say, for people who don’t use a lot of medical care or who have cash on hand for a health crisis.

But while people with an excruciating earache will seek care, McCoy said, those with unhealthy blood sugar levels might not feel as urgent a need to seek treatment — despite the potential long-term damage — given the acute financial pain.

“You have no symptoms until it’s too late,” she said. “At that point, the damage is irreversible.”

Overall, medical care for people with diabetes costs insurers and patients an average of the disease, according to an analysis. Type 2 diabetes, the more common form, is diagnosed when the body can no longer process or produce enough insulin to adequately regulate blood sugars. With Type 1, the body can’t produce insulin. Those with the disease may end up on the financial hook not just for insulin and other types of medication but for related equipment.

Mallory Rogers, whose 6-year-old daughter, Adeline, has Type 1, calculates that it costs roughly $1,200 a month for insulin, a pump, and a continuous glucose monitor. That figure doesn’t include the cost of emergency supplies needed in case Adeline’s technology malfunctions. Those include another type of insulin, blood-testing strips, and a nasal spray that’s nearly $600 for a two-pack of vials — supplies that must be replaced once a year or more frequently.

“If she doesn’t have insulin, it would become an emergency situation within two hours,” said Rogers, a technology consultant who lives in Sanford, Florida. Rogers has been saving for the coming year when her daughter moves to the high-deductible health plan offered by Rogers’ employer, which has a $3,300 deductible for family coverage.

Taxing Decisions

Many insurance plans carry increasingly high deductibles. But to be defined as a high-deductible health plan — and thus be eligible to offer a health savings account — a plan’s deductible for 2026 must be , according to IRS rules.

Health savings accounts enable people to squirrel away money that can be rolled over from year to year to be used for eligible medical expenses, including prior to meeting a deductible. Such accounts, available through a plan or employer, can provide tax benefits. The contributions are limited to $4,400 individually and $8,750 for a family in 2026, and employers may contribute toward that total. Rogers’ employer pays $2,000 spread out over the year, and Garza’s contributes $1,200.

Rogers recognizes that she’s fortunate to have accumulated $7,000 so far in her health savings account to prepare for her daughter’s insurance shifting to Rogers’ plan.

“Adding a financial burden to an already very stressful medical condition, it hurts my heart,” she said, reflecting on those who can’t similarly stockpile. “Nobody asks to have diabetes, Type 1 or Type 2.”

The median deductible for employer health insurance plans was $2,750 in 2024, but deductibles can run $5,000 or higher, said George Huntley, CEO of both the and .

When deductibles are too high, Huntley said, routine maintenance is what patients skimp on: “You don’t take the drug that you’re supposed to take to maintain your blood glucose. You ration your insulin, if that’s your scenario. You take pills every other day.”

Garza knows he should do more to control his blood sugar, but financial realities complicate the equation. His previous health plan covered a newer class of diabetes medication, called a GLP-1 agonist, for $25 a month. He wasn’t charged for his remaining medications, which included blood pressure and cholesterol drugs, or his continuous glucose monitor.

With his new insurance, he pays $125 monthly for insulin and several other medications. He doesn’t see his endocrinologist for checkups more than twice a year.

“He wants to see me every three months,” Garza said. “But I told him it’s not possible at $150 a pop.”

Plus, he typically needs lab testing before each visit, an additional $111.

In 2026, the deductible for a “silver”-level plan on the marketplace will average $5,304 without cost-sharing reductions, according to an analysis from KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News. For a . An annual visit and some preventive screenings, such as a mammogram, would be covered free of cost to the patient.

Moreover, people , whether through their employer or the marketplace, should figure out their annual out-of-pocket maximum, which still applies after the deductible is met, Huntley said.

Garza’s family policy requires him to pay 20% until he reaches $10,000, for example.

Given Garza’s high blood sugar levels, his doctor prescribed a fast-acting form of insulin to take as needed with meals, which costs an additional $79 monthly. He planned to fill it in December, when he’s responsible for only 20% of the cost after he has hit his deductible but not yet reached his out-of-pocket maximum.

Garza likes his job despite its health plan, saying he’s never missed a day of work, even recently when he had a stomach bug. As of late 2025, he remained conflicted about whether to sign up for health insurance when his company’s enrollment period rolls around in mid-2026.

He worries that dropping insurance would place his family too much at risk if a major medical crisis struck. Still, he pointed out, he could then use the money he now spends on monthly premiums to directly pay for care to better manage his diabetes.

“I’m just stuck, to be honest with you,” he said.

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Bynum, then in his second year of residency training as a family medicine physician, was wrapping up a long shift when he was called into an emergency delivery. To save the baby’s life, he used a vacuum device, which applies suction to assist with rapid delivery.

The baby emerged unharmed. But the mother suffered a severe vaginal tear that required surgical repair by an obstetrician. Soon afterward, Bynum retreated to an empty hospital room, trying to process his feelings about the unexpected complication.

“I didn’t want to see anybody. I didn’t want anybody to find me,” said Bynum, now an at Duke University School of Medicine in North Carolina. “It was a really primitive response.”

Shame is a common and highly uncomfortable human emotion. In the years since that pivotal incident, Bynum has become a among clinicians and researchers who argue that the intense crucible of medical training can amplify shame in future doctors.

He is now part of an emerging effort to teach what he describes as “” to medical school students and practicing physicians. While shame can’t be eliminated, Bynum and his research colleagues maintain that related skills and practices can be developed to reduce the culture of shame and foster a healthier way to engage with it.

Without this approach, they argue, tomorrow’s doctors won’t recognize and address the emotion in themselves and others. And thus, they risk transmitting it to their patients, even inadvertently, which may . Shaming patients can backfire, Bynum said, making them defensive and leading to isolation and sometimes substance use.

The U.S. political environment presents an additional obstacle. Health and Human Services Secretary Robert F. Kennedy Jr. and other top Trump administration health officials have autism, diabetes, attention-deficit/hyperactivity disorder, and other chronic issues in large part on the lifestyle choices of people with the conditions — or their parents. For instance, FDA Commissioner Marty Makary suggested in a Fox News interview that diabetes could be better treated with cooking classes than “.”

Even before the political shift, that attitude was reflected at doctors’ offices as well. A 2023 study found that when treating patients with Type 2 diabetes. About 44% viewed those patients as lacking motivation to make lifestyle changes, while 39% said they tended to be lazy.

“We don’t like feeling shame. We want to avoid it. It’s very uncomfortable,” said , a nurse at the University of Wisconsin-Madison, who has of related studies, published in 2024. And if the source of shame is from the clinician, the patient may ask, “‘Why would I go back?’ In some cases, that patient may generalize that to the whole health care system.”

Indeed, Christa Reed dropped out of regular medical care for two decades, weary of weight-related lectures. “I was told when I was pregnant that my morning sickness was because I was a plus-size, overweight woman,” she said.

Except for a few urgent medical issues, such as an infected cut, Reed avoided health care providers. “Because going into a doctor for an annual visit would be pointless,” said the now 45-year-old Minneapolis-area wedding photographer. “They would only just tell me to lose weight.”

Then, last year, severe jaw pain drove Reed to seek specialty care. A routine blood pressure check showed a sky-high reading, sending her to the emergency room. “They said, ‘We don’t know how you’re walking around normal,’” she recounted.

Since then, Reed has found supportive physicians with expertise in nutrition. Her blood pressure remains under control with medication. She’s also nearly 100 pounds below her heaviest weight, and she hikes, bikes, and lifts weights to build muscle.

, a California psychiatrist, is among a group of physicians trying to bring attention to the detrimental effects of shame and develop strategies to prevent and mitigate it. While this effort is in the early stages, she co-led a session on the spiral of shame at the American Psychiatric Association’s annual meeting in May.

If physicians don’t acknowledge shame in themselves, they can be at risk of depression, , sleeping difficulties, and other ripple effects that erode patient care, she said.

“We often don’t talk about how important the human connection is in medicine,” Woodward said. “But if your doctor is burned out or feeling like they don’t deserve to be your doctor, patients feel that. They can tell.”

In a survey conducted this year, 37% of graduating students at some point in medical school. And nearly 20% described public humiliation, according to the annual survey by the Association of American Medical Colleges.

Medical students and resident physicians are already prone to perfectionism, along with an almost “masochistic” work ethic, as Woodward described it. Then they’re run through a gantlet of exams and years of training, amid constant scrutiny and with patients’ lives on the line.

During training, physicians work in teams and make presentations to teaching faculty about a patient’s medical issues and their recommended treatment approach. “You trip over your words. You miss things. You get things out of order. You go blank,” Bynum said. And then shame creeps in, he said, leading to other debilitating thoughts, such as “‘I’m no good at this. I’m an idiot. Everyone around me would have done this so much better.’”

Yet shame remains “a crack in your armor that you don’t want to show,” said , a family medicine physician at the University of Utah who has taught medical students about the potential for shame as part of a broader ethics and humanities course.

“You’re taking care of a human life,” she said. “Heaven forbid that you act like you’re not capable or you show fear.”

When students are taught about shame, the goal is to help future physicians recognize the emotion in themselves and others, so they don’t perpetuate the cycle, Pippitt said. “If you felt shamed throughout your medical education, it normalizes that as the experience,” she said.

Above all, physicians-in-training can work to reframe their mindset when they receive a poor grade or struggle to master a new skill, said Woodward, the California psychiatrist. Instead of believing that they’ve failed as a physician, they can focus on what they got wrong and ways to improve.

Last year, Bynum started teaching Duke physicians about shame competence, beginning with roughly 20 OB-GYN residents. This year, he launched a larger initiative with , a research and training partnership between Duke University and the University of Exeter in England that he co-founded, to reach about 300 people across Duke’s Department of Family Medicine and Community Health, including faculty and residents.

This sort of training is rare among Duke OB-GYN resident ’s peers in other programs. Dancel, who completed the training, now strives to support students as they learn skills such as how to suture. She hopes they will pay that approach forward in “a chain reaction of being kind to each other.”

More than a decade after Bynum experienced that stressful emergency delivery, he still regrets that shame kept him from checking on the mother as he usually would following delivery. “I was too scared of how she was going to react to me,” he said.

“It was a little devastating,” he said, when a colleague later told him that the mother wished he had stopped by. “She had passed a message along to thank me for saving her baby’s life. If I had just given myself a chance to hear that, that would have really helped in my recovery, to be forgiven.”

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After the 36-year-old was diagnosed with stage 3 breast cancer in December, she learned that there weren’t any cancer services in her community of Del Rio, a town of 35,000 near the Texas-Mexico border.

To get treatment, she and her husband, Manuel, must drive nearly three hours east to San Antonio. So they set an alarm for 4 a.m., which allows for just enough time to roll out of bed, brush their teeth, and begin the long drive navigating dark roads while watching for deer.

About an hour before they arrive at the cancer clinic, the couple pulls over to quickly eat fast food in the car. The break gives Herlinda time to apply ointment on the port where the needle for her chemotherapy will be inserted.

“It numbs the area, so when I get to the infusion room the needle won’t hurt,” she said.

For rural patients, getting cancer treatment close to home has always been difficult. But in recent years, chemotherapy deserts have expanded across the United States, with 382 rural from 2014 to 2022, according to a report published this year by Chartis, a health analytics and consulting firm.

Texas led that list, with 57 rural hospitals — nearly half of those statewide that had offered chemotherapy — cutting the service by 2022, according to the analysis. Rural hospitals in states like Texas, which hasn’t expanded Medicaid, have been more likely to close, according to data from the Cecil G. Sheps Center for Health Services Research.

To keep the doors open, in small communities nationwide continue to shed basic health care services, like obstetrics and chemotherapy, said Michael Topchik, executive director of the Chartis Center for Rural Health.

“The data are staggering,” Topchik said. “Can you imagine feeling that sick, and having to drive an hour in each direction, or maybe more each direction, several times a week?”

Loss of chemotherapy services can signal other gaps in cancer care, such as a shortage of local specialty physicians and nurses, which is bad news for patients, said Marquita Lewis-Thames, an assistant professor at Northwestern University in Chicago whose research covers rural cancer care.

Rural patients are less likely to survive at least five years after a cancer diagnosis compared with their urban counterparts, concluded a and published in JAMA Network Open in 2022. While the rural-urban survival gap narrowed over the nearly 40 years researchers studied, the disparity persisted across most racial and ethnic groups, with only a few exceptions, she said.

Many cancer drugs are now given orally and can be taken at home, but some treatments for breast, colon, and other common cancers must still be administered intravenously inside a medical facility. Even distances of an hour or two each way can strain patients who already may be coping with nausea, diarrhea, and other side effects, physicians and patient advocates said.

“It’s pretty uncomfortable for some of these patients who may have bone metastases or have significant muscular pain and have to sit in the car that long and hit road bumps,” said Shivum Agarwal, a family physician who practices in rural communities an hour west of Fort Worth, Texas.

Plus, travel can cost much more than filling the gas tank.

“Usually it requires an able-bodied family member taking off a whole day or at least half a day from work,” Agarwal said. “So, there’s a big economic cost for the family.”

In this sense, the Sanchez family is fortunate. Herlinda’s mother drives four hours from Abilene to Del Rio to watch the couple’s youngest children, their 2-year-old twins.

Cancer infusions can last as long as eight hours on top of the travel time, causing significant financial and logistical challenges, said Erin Ercoline, executive director of the San Antonio-based ThriveWell Cancer Foundation. The nonprofit provides adult patients with financial assistance, including for gaps in insurance and transportation-related costs. It has helped cover gasoline for Sanchez, who received her final round of chemotherapy in late June. The financial assistance will also pay for her hotel when she travels for breast surgery this month.

Not all rural hospitals are ending chemotherapy. Childress Regional Medical Center, a 39-bed hospital in West Texas, is constructing a 6,000-square-foot center for patients who need infusions for cancer and other diagnoses, including multiple sclerosis and rheumatology.

The infusion area, which started with two chairs in 2013 and now has four, will grow to 10 chairs and have more patient privacy when it opens next year. The next-nearest infusion center in this sprawling region is an hour or more away, which discourages some patients from seeking care, said Childress’ CEO, Holly Holcomb.

“We’ve had a handful of patients say, ‘If you can’t do it here, I’m not doing it,’” Holcomb said. She credits the federal 340B drug discount program for enabling the remote hospital to provide infusion drugs.

Hospitals that qualify for 340B can buy outpatient drugs at steep discounts. The program provides “a huge kickstand for rural hospitals,” said Topchik, of Chartis Center. Hospitals can use the savings to buoy or expand services provided to the community, he said.

But some patients are not daunted by long drives and travel costs.

“I’m from the country, so small is better — it’s just more personable,” said Dennis Woodward, 69, who lives in Woodson, Texas. He has a type of non-Hodgkin lymphoma and chooses to make a two-hour drive to Childress. He had first visited an oncology clinic in Abilene about an hour away. The clinicians were nice, but “I felt like a number,” he said.

After his first appointment at Childress this year, his oncologist, Fred Hardwicke, walked him over to meet the nurses who would administer the medicine, Woodward recalled.

Most Fridays during Herlinda Sanchez’s chemotherapy, Manuel would nap in the car. But during her final treatment in June, he stayed nearby, counting down the hours.

Several family members joined Herlinda when she rang the bell later that afternoon to signal the end of her treatment.

“I don’t want to be in San Antonio no more,” said Herlinda, a mother of four who does administrative work at Laughlin Air Force Base near Del Rio. “I’m looking forward to the break.”

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“I remember that drive home, bringing her back home, and we basically cried,” said the internal medicine physician, who had started practicing in eastern Kentucky near his childhood home shortly before his mother began feeling ill. “Nobody wants to get told they’ve got inoperable lung cancer. I cried because I knew what this meant for her.”

Now Stumbo, whose mother died the following year, in 1997, is among a group of Kentucky clinicians and researchers determined to rewrite the script for other families by promoting training and boosting awareness about early detection in the state with the highest lung cancer death rate. For the past decade, Kentucky researchers have promoted lung cancer screening, first recommended by the U.S. Preventive Services Task Force in 2013. These days the Bluegrass State screens more residents who are at high risk of developing lung cancer than any state except Massachusetts — 10.6% of eligible residents in 2022, more than double the national rate of 4.5% — according to the most recent American Lung Association analysis.

The effort has been driven by a research initiative called the , which in 2014 launched to improve screening and prevention, to identify more tumors earlier, when survival odds are far better. The group has worked with clinicians and hospital administrators statewide to boost screening rates both in urban areas and regions far removed from academic medical centers, such as rural Appalachia. But, a decade into the program, the researchers face an ongoing challenge as they encourage more people to get tested, namely the fear and stigma that swirl around smoking and lung cancer.

Lung cancer kills more Americans than any other malignancy, and the death rates are worst in a swath of states including Kentucky and its neighbors Tennessee and West Virginia, and stretching south to Mississippi and Louisiana, from the Centers for Disease Control and Prevention.

It’s a bit early to see the impact on lung cancer deaths because people may still live for years with a malignancy, LEADS researchers said. Plus, treatment improvements and other factors may also help reduce death rates along with increased screening. Still, data already shows that more cancers in Kentucky are being detected before they become advanced, and thus more difficult to treat, they said. Of total lung cancer cases statewide, the percentage of advanced cases — defined as cancers that had spread to the lymph nodes or beyond — hovered near 81% between 2000 and 2014, according to Kentucky Cancer Registry data. By 2020, that number had declined to 72%, according to the most recent data available.

“We are changing the story of families. And there is hope where there has not been hope before,” said Jennifer Knight, a LEADS principal investigator.

Older adults in their 60s and 70s can hold a particularly bleak view of their mortality odds, given what their loved ones experienced before screening became available, said Ashley Shemwell, a nurse navigator for the lung cancer screening program at Owensboro Health, a nonprofit health system that serves Kentucky and Indiana.

“A lot of them will say, ‘It doesn’t matter if I get lung cancer or not because it’s going to kill me. So I don’t want to know,’” said Shemwell. “With that generation, they saw a lot of lung cancers and a lot of deaths. And it was terrible deaths because they were stage 4 lung cancers.” But she reminds them that lung cancer is much more treatable if caught before it spreads.

The collaborative works with several partners, including the University of Kentucky, the University of Louisville, and GO2 for Lung Cancer, and has received grant funding from the Bristol Myers Squibb Foundation. Leaders have provided training and other support to 10 hospital-based screening programs, including a stipend to pay for resources such as educational materials or a nurse navigator, Knight said. In 2022, state lawmakers established a statewide lung cancer screening program based in part on the group’s work.

Jacob Sands, a lung cancer physician at Boston’s Dana-Farber Cancer Institute, credits the LEADS collaborative with encouraging patients to return for annual screening and follow-up testing for any suspicious nodules. “What the Kentucky LEADS program is doing is fantastic, and that is how you really move the needle in implementing lung screening on a larger scale,” said Sands, who isn’t affiliated with the Kentucky program and serves as a volunteer spokesperson for the American Lung Association.

In 2014, Kentucky expanded Medicaid, increasing the number of lower-income people who qualified for lung cancer screening and any related treatment. Adults 50 to 80 years old are advised to get a CT scan every year if they have accumulated at least 20 pack years and still smoke or have quit within the past 15 years, according to the latest task force recommendation, which widened the pool of eligible adults. (To calculate pack years, multiply the packs of cigarettes smoked daily by years of smoking.) The lung association offers an online quiz, called “,” to figure out likely eligibility for insurance coverage.

Half of U.S. patients aren’t diagnosed until their cancer has spread beyond the lungs and lymph nodes to elsewhere in the body. By then, the five-year survival rate is 8.2%.

But regular screening boosts those odds. When a CT scan detects lung cancer early, patients have an 81% chance of living at least 20 years, according to data published in November in the journal Radiology.

Some adults, like Lisa Ayers, didn’t realize lung cancer screening was an option. Her family doctor recommended a CT scan last year after she reported breathing difficulties. Ayers, who lives in Ohio near the Kentucky border, got screened at UK King’s Daughters, a hospital in far eastern Kentucky. The scan didn’t take much time, and she didn’t have to undress, the 57-year-old said. “It took me longer to park,” she quipped.

She was diagnosed with a lung carcinoid tumor, a type of neuroendocrine cancer that can grow in various parts of the body. Her cancer was considered too risky for surgery, Ayers said. A biopsy showed the cancer was slow-growing, and her doctors said they would monitor it closely.

Ayers, a lifelong smoker, recalled her doctor said that her type of cancer isn’t typically linked to smoking. But she quit anyway, feeling like she’d been given a second chance to avoid developing a smoking-related cancer. “It was a big wake-up call for me.”

Adults with a smoking history often report being treated poorly by medical professionals, said Jamie Studts, a health psychologist and a LEADS principal investigator, who has been involved with the research from the start. The goal is to avoid stigmatizing people and instead to build rapport, meeting them where they are that day, he said.

“If someone tells us that they’re not ready to quit smoking but they want to have lung cancer screening, awesome; we’d love to help,” Studts said. “You know what? You actually develop a relationship with an individual by accepting, ‘No.’”

Nationally, screening rates vary widely. Massachusetts reaches 11.9% of eligible residents, while California ranks last, screening just 0.7%, according to the lung association analysis.

That data likely doesn’t capture all California screenings, as it may not include CT scans done through large managed care organizations, said Raquel Arias, a Los Angeles-based associate director of state partnerships at the American Cancer Society. She cited other 2022 data for California, looking at lung cancer screening for eligible Medicare fee-for-service patients, which found a screening rate of 1%-2% in that population.

But, Arias said, the state’s effort is “nowhere near what it needs to be.”

The low smoking rate in California, along with its image as a healthy state, “seems to have come with the unintended consequence of further stigmatizing people who smoke,” said Arias, citing one of the findings from a 2022 report looking at lung cancer screening barriers. For instance, eligible patients may be reluctant to share prior smoking habits with their health provider, she said.

Meanwhile, Kentucky screening efforts progress, scan by scan.

At Appalachian Regional Healthcare, 3,071 patients were screened in 2023, compared with 372 in 2017. “We’re just scratching the surface of the potential lives that we can have an effect on,” said Stumbo, a lung cancer screening champion at the health system, which includes 14 hospitals, most located in eastern Kentucky.

The doctor hasn’t shed his own grief about what his family missed after his mother died at age 51, long before annual screening was recommended. “Knowing that my children were born, and never knowing their grandmother,” he said, “just how sad is that?”

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By then, the reddish area along her hairline had grown from a 2-inch circle to cover nearly her entire forehead. It oozed fluid and was painful.

“Honestly, I was just waiting on it to kill me, because I thought that’s what was going to have to happen,” said the 41-year-old mother of three, who lives in Easley, South Carolina.

Adcox had first met with physicians at the academic medical center in late 2020, after a biopsy diagnosed basal cell carcinoma. The operation to remove the cancer would require several physicians, she was told, including a neurosurgeon, because of how close it was to her brain.

But Adcox was uninsured. She had lost her automotive plant job in the early days of the pandemic, and at the time of her diagnosis was equally panicked about the complex surgery and the prospect of a hefty bill. Instead of proceeding with treatment, she attempted to camouflage the expanding cancerous area for more than a year with hats and long bangs.

If Adcox had developed breast or cervical cancer, she likely would have qualified for insurance coverage under a federal law that extends Medicaid eligibility to lower-income patients diagnosed with those two malignancies. For female patients with other types of cancer, as well as pretty much all male patients, the options are scant, especially in that haven’t yet implemented Medicaid expansion, according to cancer physicians and health policy experts who study access to care.

In the face of potentially daunting bills, uninsured adults sometimes delay care, which can result in worse survival outcomes, . The odds of patients getting insurance to help cover the cost of treatment play out a bit like a game of roulette, depending upon where they live and what type of cancer they have.

“It is very random — that’s, I think, the heartbreaking part about it,” said Dr. Evan Graboyes, a head and neck surgeon and one of Adcox’s physicians. “Whether you live or die from cancer shouldn’t really be related to what state you live in.”

The Affordable Care Act gave states the option to expand Medicaid eligibility and cover more people. Shortly after the law passed, with a new cancer diagnosis lacked insurance in Medicaid expansion states versus 7.8% in nonexpansion states, according to a study published in JAMA Oncology in 2018. Researchers at the American Cancer Society, who conducted the analysis, estimate that about 30,000 uninsured people are diagnosed with cancer each year.

But in all states, lower-income uninsured patients with breast or cervical cancer may have another route for coverage, even if they don’t otherwise qualify for Medicaid. Adults with cancer detected through the can enroll in Medicaid for the duration of their cancer treatment, as a result of advocacy efforts and federal legislation that started more than three decades ago.

In 2019, 43,549 breast and cervical cancer patients were enrolled, according to a published in 2020.

“If you’re lucky to be diagnosed with breast or cervical cancer, you’re good,” said Dr. Fumiko Chino, a radiation oncologist at Memorial Sloan Kettering Cancer Center in New York City, who studies cancer treatment access and affordability. “But otherwise, you may have some significant obstacles.”

The total amount billed to the insurer during the year following a cancer diagnosis can be steep. For instance, costs in 2016 averaged , according to a 2022 study that calculated insurance claims for several common malignancies diagnosed in privately insured patients.

Since uninsured adults can struggle to afford preventive care, their cancer may not be identified until it’s more advanced, making it costlier for the patient and the health system, said Robin Yabroff, an author of the study in JAMA Oncology and a scientific vice president at the American Cancer Society.

Patients who can’t get financial assistance through a safety-net facility sometimes rack up medical debt, use credit cards, or launch fundraising efforts though online sites, Yabroff said. “We hear stories of people who mortgage their homes to pay for cancer treatment.”

Cancer patients can purchase insurance through the ACA health insurance marketplace. But they often must wait until the regular enrollment period near the end of the year, and those health plans don’t become effective until the start of the next calendar year.

That’s because the federal law was designed to encourage people to sign up when they are healthy, which helps control costs, said MaryBeth Musumeci, an associate teaching professor of health policy and management at George Washington University in Washington, D.C. If a new diagnosis were a qualifying event for new coverage, she said, “then it would incentivize people to stay uninsured while they were healthy and they didn’t think they really were going to need coverage.”

Meanwhile, the on-ramp to Medicaid coverage for lower-income patients with breast and cervical cancer is a story of successful advocacy, dating to a that created the national breast and cervical screening program. Mammography started to be , and advocacy groups pushed to reach more underserved individuals, said Katie McMahon, a policy principal at the American Cancer Society Cancer Action Network, the organization’s advocacy arm.

But research showed that some uninsured adults struggled to get care for those cancers detected through the screening program, McMahon said. A 2000 law to them, and by 2008 all 50 states and the District of Columbia had done so, according to the 2020 GAO report.

For other cancer patients, one of the remaining avenues to coverage, according to Chino, is to qualify for disability through the Social Security Administration, after which they can apply for Medicaid. The federal agency has a for cancer patients. It also has a , which offers faster reviews for patients with certain serious medical conditions, including advanced or aggressive cancers.

Although the rules vary, many patients don’t qualify until their disease has spread or the cancer requires at least a year of intense treatment, Chino said. That presents an inherent catch-22 for people who are uninsured but have curable types of cancer, she said.

“To qualify for Medicaid, I have to wait for my cancer to be incurable,” she said, “which is very depressing.”

For example, the Compassionate Allowances program doesn’t list basal cell carcinoma, and it covers head and neck cancer only if it has spread elsewhere in the body or can’t be removed surgically.

Adcox said that before her 12-hour operation last June, her financial assistance application with the Medical University of South Carolina was still pending. Someone from the hospital, she recalled, estimated the bill would be $176,000 and asked how much Adcox could put down. She cobbled together $700 with the help of loved ones.

But she did qualify for financial assistance and hasn’t received any bills, except from an outside lab services provider. “It’s over,” Adcox said. She’s since undergone radiation and will have more reconstructive surgeries. But she’s cancer-free. “It didn’t kill me. It didn’t kill me.”

Still, not everyone finds a safety net.

Brian Becker, of El Paso, Texas, was uninsured and not working when he learned he had chronic myelogenous leukemia in summer 2021, said Stephanie Gamboa, his ex-wife and the mother of their young daughter. His cancer physician required an upfront payment, she said, and it took several months to borrow enough money.

He started chemotherapy the following year, and over months lost weight and became weaker, returning to the emergency room with infections and worsening kidney function, Gamboa said. The last time their daughter saw her father, “he couldn’t get out of bed. He was literally skin and bones,” Gamboa said.

Becker started the process to request disability benefits. The text he sent Gamboa, which she shared with KHN, stated that review of his application began in June 2022 and was expected to take six months.

The denial letter, dated Feb. 4, 2023, arrived more than a month after at age 32. It read in part: “Based on a review of your medical conditions, you do not qualify for benefits on this claim.”

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Cancer coincides with roughly 1 in 1,000 pregnancies, most frequently breast cancer, melanoma, cervical cancer, lymphomas, and leukemias. But medications and other treatments can be toxic to the developing fetus or cause birth defects. In some cases, hormones that are supercharged during pregnancy fuel the cancer’s growth, putting the patient at greater risk.

Although new abortion restrictions often allow exceptions based on “medical emergency” or a “life-threatening physical condition,” cancer physicians describe the legal terms as unclear. They fear misinterpreting the laws and being left in the lurch.

For instance, brain cancer patients have traditionally been offered the option of abortion if a pregnancy might limit or delay surgery, radiation, or other treatment, said Dr. Edjah Nduom, a brain cancer surgeon at Emory University’s Winship Cancer Institute in Atlanta.

“Is that a medical emergency that necessitates the abortion? I don’t know,” Nduom asked, trying to parse the medical emergency exception . “Then you end up in a situation where you have an overzealous prosecutor who is saying, ‘Hey, this patient had a medical abortion; why did you need to do that?’” he said.

Pregnant patients with cancer should be treated similarly to non-pregnant patients when feasible, though sometimes adjustments are made in the timing of surgery and other care, according to , published in 2020 in Current Oncology Reports.

With breast cancer patients, surgery could be performed early on as part of the treatment, pushing chemotherapy to later in the pregnancy, according to the research. Cancer experts typically recommend avoiding radiation therapy throughout pregnancy, and most chemotherapy drugs during the first trimester.

But with some cancers, such as acute leukemia, the recommended drugs have known toxic risks to the fetus, and time is not on the patient’s side, said Dr. Gwen Nichols, chief medical officer of the Leukemia & Lymphoma Society.

“You need treatment urgently,” she said. “You can’t wait three months or six months to complete a pregnancy.”

Another life-threatening scenario involves a patient early in her pregnancy who has been diagnosed with breast cancer that’s spreading, and tests show that the cancer’s growth is spurred by the hormone estrogen, said Dr. Debra Patt, an oncologist in Austin, Texas, who estimated she has cared for more than two dozen pregnant patients with breast cancer.

“Pregnancy is a state where you have increased levels of estrogen. It’s actually actively at every moment causing the cancer to grow more. So I would consider that an emergency,” said Patt, who is also executive vice president over policy and strategic initiatives at Texas Oncology, a statewide practice with more than 500 physicians.

When cancer strikes individuals of child-bearing age, one challenge is that malignancies tend to be more aggressive, said Dr. Miriam Atkins, an oncologist in Augusta, Georgia. Another is that it’s unknown whether some of the newer cancer drugs will affect the fetus, she said.

While hospital ethics committees might be consulted about a particular treatment dilemma, it’s the facility’s legal interpretation of a state’s abortion law that will likely prevail, said Micah Hester, an expert on ethics committees who chairs the department of medical humanities and bioethics at the University of Arkansas for Medical Sciences College of Medicine in Little Rock.

“Let’s be honest,” he said. “The legal landscape sets pretty strong parameters in many states on what you can and cannot do.”

It’s difficult to fully assess how physicians plan to handle such dilemmas and discussions in states with near-total abortion bans. Several large medical centers contacted for this article said their physicians were not interested or not available to speak on the subject.

Other physicians, including Nduom and Atkins, said the new laws won’t alter their discussions with patients about the best treatment approach, the potential impact of pregnancy, or whether abortion is an option.

“I’m going to always be honest with patients,” Atkins said. “Oncology drugs are dangerous. There are some drugs that you can give to [pregnant] cancer patients; there are many that you cannot.”

The bottom line, maintain some, is that termination remains a critical and legal part of care when cancer threatens someone’s life.

Patients “are counseled on the best treatment options for them, and the potential impacts on their pregnancies and future fertility,” Dr. Joseph Biggio Jr., chair of maternal-fetal medicine at Ochsner Health System in New Orleans, wrote in an email. “Under state laws, pregnancy termination to save the life of the mother is legal.”

Similarly, Patt said that physicians in Texas can counsel pregnant patients with cancer about the procedure if, for instance, treatments carry documented risks of birth defects. Thus, physicians can’t recommend them, and abortion can be offered, she said.

“I don’t think it’s controversial in any way,” Patt said. “Cancer left unabated can pose serious risks to life.”

Patt has been educating physicians at Texas Oncology on , as well as sharing a JAMA Internal Medicine editorial that . “I feel pretty strongly about this, that knowledge is power,” she said.

Still, the Texas law’s vague terminology complicates physicians’ ability to determine what’s legally permissible care, said Joanna Grossman, a professor at SMU Dedman School of Law. She said nothing in the statute tells a doctor “how much risk there needs to be before we label this legally ‘life-threatening.’”

And if a woman can’t obtain an abortion through legal means, she has “grim options,” according to Hester, the medical ethicist. She’ll have to sort through questions like: “Is it best for her to get the cancer treatment on the time scale recommended by medicine,” he said, “or to delay that cancer treatment in order to maximize the health benefits to the fetus?”

Getting an abortion outside Georgia might not be possible for patients with limited cash or no backup child care or who share one car with an extended family, Atkins said. “I have many patients who can barely travel to get their chemotherapy.”

Dr. Charles Brown, a maternal-fetal medicine physician in Austin who retired this year, said he can speak more freely than practicing colleagues. The scenarios and related unanswered questions are almost too numerous to count, said Brown, who has cared for pregnant women with cancer.

Take as another example, he said, a potential situation in a state that incorporates “fetal personhood” in its law, such as Georgia. What if a patient with cancer can’t get an abortion, Brown asked, and the treatment has known toxic effects?

“What if she says, ‘Well, I don’t want to delay my treatment — give me the medicine anyway,’” Brown said. “And we know that medicine can harm the fetus. Am I now liable for harm to the fetus because it’s a person?”

Whenever possible, physicians have always strived to treat the patient’s cancer and preserve the pregnancy, Brown said. When those goals conflict, he said, “these are gut-wrenching trade-offs that these pregnant women have to make.” If termination is off the table, “you’ve removed one of the options to manage her disease.”

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As the Supreme Court appears poised to return abortion regulation to the states, recent experience in Texas illustrates that medical care for miscarriages and dangerous ectopic pregnancies would also be threatened if restrictions become more widespread.

One passed last year lists several medications as abortion-inducing drugs and largely bars their use for abortion after the seventh week of pregnancy. But two of those drugs, misoprostol and mifepristone, are the only drugs recommended in the American College of Obstetricians and Gynecologists guidelines for treating a patient after an early pregnancy loss. The other miscarriage treatment is a procedure described as surgical uterine evacuation to remove the pregnancy tissue — the same approach as for an abortion.

“The challenge is that the treatment for an abortion and the treatment for a miscarriage are exactly the same,” said Dr. , a professor of obstetrics and gynecology at the University of Washington in Seattle and an expert in early pregnancy loss.

Miscarriages occur in roughly 1 out of 10 pregnancies. Some people experience loss of pregnancy at home and don’t require additional care, other than emotional support, said Dr. , who chairs the OB-GYN department at the University of Texas-Rio Grande Valley School of Medicine. But in other situations, he said, providers may need to intervene to stop bleeding and make sure no pregnancy tissue remains, as a guard against infection.

Dr. , an OB-GYN and assistant professor at the Dell Medical School at the University of Texas-Austin, has already heard about local patients who have been miscarrying, and couldn’t get a pharmacy to fill their misoprostol prescription. “The pharmacy has said, ‘We don’t know whether or not you might be using this medication for the purposes of abortion,’” she said.

Thaxton, who supervises the obstetrics-gynecology residents who have seen these patients, said sometimes the prescribing clinic will intervene, but it takes the patient longer to get the medication. Other times patients don’t report the problem and miscarry on their own, she said, but without medication they risk additional bleeding.

Under another new Texas abortion law, someone who “aids or abets” an abortion after cardiac activity can be detected, typically around six weeks, can be subject to at least a $10,000 fine per occurrence. Anyone can bring that civil action, posing a quandary for physicians and other providers. How do they follow the latest guidelines when other people — from medical professionals to friends and family members — can question their intent: Are they helping care for a miscarriage or facilitating an abortion?

Sometimes patients don’t realize that they have lost the pregnancy until they come in for a checkup and no cardiac activity can be detected, said Dr. Emily Briggs, a family physician who delivers babies in New Braunfels, Texas. At that point, the patient can opt to wait until the bleeding starts and the pregnancy tissue is naturally released, Briggs said. For some, that’s too difficult, given the emotions surrounding the pregnancy loss, she said. Instead, the patient may choose medication or a surgical evacuation procedure, which Briggs said may prove necessary anyway to avoid a patient becoming septic if some of the tissue remains in the uterus.

But now in Texas, the new laws are creating uncertainties that may deter some doctors and other providers from offering optimal miscarriage treatment.

These situations can create significant moral distress for patients and providers, said , a bioethicist and assistant professor of medical education at the University of North Texas Health Science Center in Fort Worth. “Any law that creates a hesitancy for physicians to uphold the standard of care for a patient has a cascade of harmful effects both for the patient but also for everyone else,” said Esplin.

It’s an emotional and legal dilemma that potentially faces not just obstetricians and midwives, but also family physicians, emergency physicians, pharmacists, and anyone else who might become involved with pregnancy care. And Ogburn, who noted that he was speaking personally and not for the medical school, worries that fears about the Texas laws have already delayed care.

“I wouldn’t say this is true for our practice,” he said. “But I have certainly heard discussion among physicians that they’re very hesitant to do any kind of intervention until they’re absolutely certain that this is not possibly a viable pregnancy — even though the amount of bleeding would warrant intervening because it’s a threat to the mother’s life.”

John Seago, legislative director for , described this type of hesitation as “an awful misunderstanding of the law.” Even before the passage of the two bills, existing Texas law stated that the act is not an abortion if it involves the treatment of an ectopic pregnancy — which most commonly occurs when the pregnancy grows in the fallopian tube — or to “remove a dead, unborn child whose death was caused by spontaneous abortion,” he said, pointing to the statute. Another area of Texas law that Seago cited provides an exception to the state’s abortion restrictions if the mother’s life is in danger or she’s at “serious risk of substantial impairment of a major bodily function” unless an abortion is performed.

“It is a pro-life position to allow physicians to make those life-and-death decisions,” Seago said. “And that may mean in certain circumstances protecting the mother in this situation and the child passing away.”

But interpretation of the laws is still causing challenges to care. At least several OB-GYNs in the Austin area received a letter from a pharmacy in late 2021 saying it would no longer fill the drug methotrexate in the case of ectopic pregnancy, citing the recent Texas laws, said Dr. Charlie Brown, an Austin-based obstetrician-gynecologist who provided a copy to KHN. Methotrexate also is listed in the Texas law passed last year.

Ectopic pregnancy develops in an estimated 2% of reported pregnancies. Methotrexate or surgery are the only two options listed in the medical guidelines to prevent the fallopian tubes from rupturing and causing dangerous bleeding.

“Ectopic pregnancies can kill people,” said Brown, a district chair for the American College of Obstetricians and Gynecologists, representing Texas.

, a professor of law at Southern Methodist University’s Dedman School of Law in Dallas, understands why some in Texas’ pharmacy community might be nervous. “The penalties are quite draconian,” he said, noting that someone could be convicted of a felony.

However, Mayo said that his reading of the law allows for the use of methotrexate to treat an ectopic pregnancy. In addition, he said, other Texas laws and the Roe v. Wade decision provide an exception to permit abortion if a pregnant person’s life is in danger.

Since the Texas laws include a stipulation that there must be intent to induce an abortion, Mayo said that he’d advise physicians and other clinicians to closely document the rationale for medical care, whether it’s to treat a miscarriage or an ectopic pregnancy.

But Prager believes that the laws in Texas — and perhaps elsewhere soon — could boost physicians’ vulnerability to medical malpractice lawsuits. Consider the patient whose miscarriage care is delayed and develops a serious infection and other complications, Prager said. “And they decide to sue for malpractice,” she said. “They can absolutely do that.”

Texas providers are still adjusting to other ripple effects that affect patient care. Dr. Jennifer Liedtke, a family physician in Sweetwater, Texas, who delivers about 175 babies annually, no longer sends misoprostol prescriptions to the local Walmart. Since the new laws took effect, Liedtke said, the pharmacist a handful of times declined to provide the medication, citing the new law — despite Liedtke writing the prescription to treat a miscarriage. Walmart officials did not respond to multiple requests for comment.

Since pharmacists rotate through that Walmart, Liedtke decided to send those prescriptions to other pharmacies rather than attempt to sort out the misunderstanding anew each time.

“It’s hard to form a relationship to say, ‘Hey look, I’m not using this for an elective abortion,’” she said. “‘I’m just using this because this is not a viable pregnancy.’”

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The other question this debate hangs on: How few is too few births?

Consider the 11-bed Providence Valdez Medical Center, which brings 40 to 60 newborns into the world each year, according to Dr. John Cullen, one of several family physicians who deliver babies at the Valdez, Alaska, hospital. The next nearest obstetrics unit is a six- to seven-hour drive away, if ice and snow don’t make the roads treacherous, he said.

The hospital cross-trains its nurses so they can care for trauma and general medicine patients along with women in labor, and it invests in simulation training to keep their skills up, Cullen said. He typically stays on-site, checking regularly as labor progresses, just a few steps away if concerns arise.

If the measure is the number of deliveries, “I do think that obviously there’s too small and we’re probably at that limit of low volume,” Cullen said. “I don’t think that we really have a choice. So, we just have to be really good at what we do.”

Some researchers have raised concerns based on their findings that hospitals with few deliveries are more likely to experience problems with those births. Meanwhile, “maternity deserts” are becoming more common. From 2004 to 2014, 9% of rural U.S. counties lost all hospital obstetric services, leaving slightly more than half of rural counties without any, according to published in 2017 in the journal Health Affairs. Yet shutting down the obstetrics unit doesn’t stop babies from arriving, either in the emergency room or en route to the next closest hospital. In addition, women may have to travel farther for prenatal care if there’s no local maternity unit.

Clinician skills and confidence suffer without sufficient practice, said Dr. Nancy Dickey, a family physician and executive director of the Texas A&M [University] Rural and Community Health Institute in College Station. So, what is that minimum threshold for baby deliveries? “I don’t have a number for you,” she said.

Dickey and Cullen are not alone in their reluctance to set a metric. For instance, the American College of Obstetricians and Gynecologists has published a about steps that rural and other low-volume facilities can take to maintain clinician skills and patient safety, including conducting frequent drills and periodically rotating health providers to higher-volume facilities to gain experience. But when asked to define “low volume,” a spokesperson wrote in an email: “We intentionally don’t define a specific number for low-volume because we do not want to create an inaccurate misperception that less volume equals less quality.”

Neither does the American Academy of Family Physicians provide guidance on what constitutes too few deliveries for safe operation. The academy “has not specified a minimum of deliveries required to maintain high quality obstetrical care in rural and underserved communities due to the unique and multifaceted nature of each case in each community,” according to a written comment from the group’s president, Dr. Sterling Ransone Jr.

One challenge in sorting out any connection between the number of deliveries and safety is that the researchers use differing cutoffs for what qualifies as a hospital with a low number of births, said Katy Kozhimannil, a professor at the University of Minnesota School of Public Health who studies rural maternal health. Plus, such data-driven analyses don’t reflect local circumstances, she said. The income level of local women, their health risk factors, the distance to the closest hospital with an obstetrics unit, hospitals’ ability to keep trained doctors and nurses — hospital leaders must consider these and other factors as they watch their birth numbers fall due to declining local population or pregnant women opting to deliver at more urban high-tech hospitals, she said.

Research on birth volumes and outcomes has been mixed, but the “more consistent” finding is that hospitals with fewer deliveries are more likely to have complications, largely because of a lack of dedicated obstetric doctors and nurses, as well as potentially fewer resources for emergencies, such as blood banks, according to the authors of a on improving rural maternity care. A , published in 2015 in the American Journal of Obstetrics & Gynecology, found that women are three times as likely to hemorrhage after delivery in rural hospitals with the lowest number of deliveries — defined as between 50 and 599 annually — as in those with 1,700 or more.

Just 7.4% of U.S. babies are born at hospitals that handle 10 to 500 births annually, according to a published last month in JAMA Network Open. But those hospitals, which researchers described as low volume, are 37% of all U.S. hospitals that deliver babies.

Finances also influence these decisions, given that half of all rural births are paid for by Medicaid, which generally reimburses providers less than private insurance. Obstetrics is “referred to as a loss leader by hospital administrators,” Kozhimannil said. As births dwindle, it can become daunting to pay for clinicians and other resources to support a service that must be available 24/7, she said. “Most hospitals will operate in the red in their obstetrics for a very long time, but at some point it can become really difficult.”

If a hospital closes its unit, most likely fewer local women will get prenatal care, and conditions like a mother’s severe anemia or a baby’s breech position will be missed, Dickey said. “Not getting prenatal care increases the risks, wherever this patient delivers.”

One Texas A&M initiative will enable its family medicine residency program to use telemedicine and periodic in-person visits to get more prenatal care to pregnant women in rural Texas, Dickey said. “What we really want are healthy mamas and healthy babies,” she said.

The rural institute Dickey leads also plans to use a mobile unit to provide maternal simulation training to emergency room clinicians at 11 rural Texas hospitals, only three of which provide obstetrics. “But all of them catch babies now and then in their ER,” said Dickey.

In Valdez, Alaska, keeping the hospital’s unit open has paid off for residents in other ways, Cullen said. Since the hospital delivers babies, including by cesarean section, there’s work to support a nurse anesthetist in the community of slightly more than 4,000 people. That enables the hospital to handle trauma calls and, more recently, the complexities of treating covid-19 patients, he said.

In her ongoing research, Kozhimannil remains committed to nailing down a range at which deliveries have dropped low enough to signal that a hospital needs “either more resources or more training because safety could be at risk.” Not to shutter the obstetrics unit, she stressed. But rather to automatically qualify that hospital for more support, including extra financing through state and federal programs given that it’s taxpayers that foot the bill for delivery complications, she said.

Because women will keep getting pregnant, Kozhimannil said, even if a hospital or a doctor decides to stop providing obstetric services. “That risk does not go away,” she said. “It stays in the community. It stays with the people, especially those that are too poor to go other places.”

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That is, unless the baby’s arrival appears imminent, and the hospital’s unit is shut down at that point. In that case, a woman would deliver in the emergency room, said Dr. Jim Luecke, who has practiced 30-plus years in the area.

But that can be a tough call, he added. Luecke described his concerns for two patients, both nearing their due date, who had previously given birth, boosting the chance of a faster delivery. “They can go from 4 centimeters dilated to completely dilated within a few minutes,” said the family physician, who estimates he’s delivered 3,000 babies.

Some pregnant women already travel an hour and a half or longer to reach the 25-bed Big Bend Regional in Alpine, said Dr. Adrian Billings, another family physician who delivers babies there. “Now to divert these ambulances at least another 60 miles away, it’s asking for more deliveries to happen en route to the hospital, and potentially poor maternal or neonatal outcomes.”

Luecke can’t recall a time when the obstetrics unit at Big Bend Regional has closed.

But it’s happening in other parts of the state: Ten rural hospitals have stopped delivering babies in the past five years or so, leaving 65 out of 157 that still do, according to the Texas Organization of Rural & Community Hospitals.

Hiring and retaining rural nurses has become even more challenging amid the pandemic as nurses have been recruited to work in urban covid-19 hot spots and sometimes don’t return to their communities, said John Henderson, chief executive officer at TORCH. More recently, some Texas hospitals have offered signing bonuses of $10,000 or more as they jockey for nurses, he said. “Covid has caused a resetting of market rates and a reshuffling of nurse staffing.”

The circumstances at Big Bend Regional, which serves a 12,000-square-mile area (about the size of Maryland), illustrates the ripple effects of potentially losing obstetric services across a broader region. The hospital, owned by Quorum Health Corp., serves a swath that extends southwest to the Mexican border and includes Big Bend National Park as well as the communities of Presidio and Candelaria. The nearest hospital, the 25-bed Pecos County Memorial in Fort Stockton, is 68 miles northeast of Alpine.

As of late July, Big Bend Regional’s obstetrics services remained in flux, with the unit closed for four- and five-day stretches, said Billings. Physicians have been told that the unit would typically remain open only Monday morning through Thursday morning of each week until more nurses arrive, he said.

The staffing crisis highlights the need for more state and national efforts to train rural nurses and other clinicians, Billings added. “The big concern that I have is that, if we don’t fix this, this could be the beginning of a rural maternity care desert out here in the Big Bend.”

The hospital, which delivered 136 babies last year, said it is “working feverishly to ensure adequate staffing levels in the coming weeks,” recruiting to fill 10 nursing positions in the labor and delivery unit, according to a statement to KHN. “When our hospital is on diversion for elective OB patients, we communicate in advance with nearby emergency transport services and acute care providers to ensure continuity of care,” the statement said.

Kelly Jones of Alpine, who worried she was having contractions, couldn’t get anyone to pick up the phone for a few hours at Big Bend’s unit in mid-July. She decided to drop off her son at a friend’s house and head to the hospital.

Jones, who is nearly full term, knew the unit had been closed a few days earlier that month but didn’t realize that closures were still occurring. “I went in and said, ‘I think I’m in labor.’ They were like, ‘Well, you can’t go into labor and delivery because they’re closed. So we’re going to take you to the ER.’” In the end, medical personnel determined she wasn’t going to deliver that day and she went home.

Since the hospital first alerted doctors last month, the unit has been on diversion July 5-9, July 14-18 and then again July 22 until Sunday, July 25, according to Billings. Efforts were being made to recruit nurses from Odessa, 150 miles away, to fill in, but the outcome was uncertain, Billings said.

Luecke scheduled an induction for one patient for July 26, when her pregnancy would be at 39 weeks — a week short of full term — and the unit was scheduled to be open. “We are trying to induce them [women] on the days that they [the hospital’s unit] are open,” he said.

Jones, who is being cared for by another physician, is scheduled for induction Aug. 2, at 39 weeks. “For a while, I was not sleeping. I was really stressed. I was panicking about every scenario,” said the 30-year-old, whose pregnancy was initially considered high risk because her son had been born prematurely.

But Jones felt better once her induction date was set. And what if the baby arrives sooner and the unit is closed? She’s been told to go to the ER, to be taken from there by ambulance to the local airport and flown to Fort Stockton.

Malynda Richardson, director of emergency medical services for the town of Presidio, which sits along the Mexican border about 90 miles from Alpine, said its first responders transport more than two dozen women with pregnancy-related issues each year, most of them in labor, including an average of two who deliver en route. First responders, including paramedics, are not typically trained to assess a woman’s cervix for dilation, making it more difficult to gauge imminent delivery, she said.

Also, when responders drive an additional two to three hours round trip to reach Fort Stockton, that affects the Presidio community, which can reliably staff only one ambulance, Richardson said. “What happens when we do have that transport [of a woman in labor] and have to go to Fort Stockton and then we have somebody else down here having a heart attack and we don’t have an ambulance available?”

Rural obstetrics units require far more nurses than doctors to remain open, so diverting women elsewhere in the short term makes sense, said Dr. Tony Ogburn, who chairs the department of obstetrics and gynecology at the University of Texas Rio Grande Valley School of Medicine. “If you don’t have trained nurses there, it doesn’t matter if you have a physician that can do a C-section or do a delivery; you can’t take care of those patients safely,” he said.

Registered nurses who work in labor and delivery have completed specialized training, such as how to read a fetal heart monitor, so a nurse from the ER or another hospital unit can’t easily step in, Billings said. “It’s kind of like having a small football team or a small soccer team and not being able to pull from the bench,” he said.

Billings said he’s reached out to Dr. Michael Galloway, who chairs the department of obstetrics and gynecology at Texas Tech University Health Sciences Center in Odessa and has been helping coordinate efforts to recruit nurses from that city. But even if Odessa nurses agree to pick up some shifts at Big Bend Regional, they are likely a stopgap solution, said Billings, who questions how long they’d be willing to work so far away from home.

Luecke believes Big Bend Regional administrators are doing everything they can to improve nurse staffing. But, like Billings, he’s worried that these July temporary closures could become longer-term.

“We are hoping August will be a different situation,” Luecke said. “But it’s pretty iffy right now.”

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That is, until October, when patients with coronavirus infections began to reappear on the unit and, with them, the fear of many more to come. “It’s paralyzing, I’m not going to lie,” said Nester, who’s worked at the Worcester hospital for nearly two decades. “My little clan of nurses that I work with, we panicked when it started to uptick here.”

Adding to that stress is that nurses are caught betwixt caring for the bedside needs of their patients and implementing policies set by others, such as physician-ordered treatment plans and strict hospital rules to ward off the coronavirus. The push-pull of those forces, amid a fight against a deadly disease, is straining this vital backbone of health providers nationwide, and that could accumulate to unstainable levels if the virus’s surge is not contained this winter, advocates and researchers warn.

Nurses spend the most sustained time with a patient of any clinician, and these days patients are often incredibly fearful and isolated, said Cynda Rushton, a registered nurse and bioethicist at Johns Hopkins University in Baltimore.

“They have become, in some ways, a kind of emotional surrogate for family members who can’t be there, to support and advise and offer a human touch,” Rushton said. “They have witnessed incredible amounts of suffering and death. That, I think, also weighs really heavily on nurses.”

A study found that 64% of clinicians working as nurses, nurse practitioners or physician assistants at a New York City hospital screened positively for acute distress, 53% for depressive symptoms and 40% for anxiety — all higher rates than found among physicians screened.

Researchers are concerned that nurses working in a rapidly changing crisis like the pandemic — with problems ranging from staff shortages that curtail their time with patients to enforcing visitation policies that upset families — can develop a psychological response called “moral injury.” That injury occurs, they say, when nurses feel stymied by their inability to provide the level of care they believe patients require.

Dr. Wendy Dean, co-founder of , a nonprofit organization based in Carlisle, Pennsylvania, said, “Probably the biggest driver of burnout is unrecognized unattended moral injury.”

In parts of the country over the summer, nurses got some mental health respite when cases declined, Dean said.

“Not enough to really process it all,” she said. “I think that’s a process that will take several years. And it’s probably going to be extended because the pandemic itself is extended.”

Sense of Powerlessness

Before the pandemic hit her Massachusetts hospital “like a forest fire” in March, Nester had rarely seen a patient die, other than someone in the final days of a disease like cancer.

Suddenly she was involved with frequent transfers of patients to the intensive care unit when they couldn’t breathe. She recounts stories, imprinted on her memory: The woman in her 80s who didn’t even seem ill on the day she was hospitalized, who Nester helped transport to the morgue less than a week later. The husband and wife who were sick in the intensive care unit, while the adult daughter fought the virus on Nester’s unit.

“Then both parents died, and the daughter died,” Nester said. “There’s not really words for it.”

During these gut-wrenching shifts, nurses can sometimes become separated from their emotional support system — one another, said Rushton, who has about preventing moral injury among health care providers. To better handle the influx, some nurses who typically work in noncritical care areas have been moved to care for seriously ill patients. That forces them to not only adjust to a new type of nursing, but also disrupts an often-well-honed working rhythm and camaraderie with their regular nursing co-workers, she said.

At St. Vincent Hospital, the nurses on Nester’s unit were told one March day that the primarily postsurgical unit was being converted to a COVID unit. Nester tried to squelch fears for her own safety while comforting her COVID-19 patients, who were often elderly, terrified and sometimes hard of hearing, making it difficult to communicate through layers of masks.

“You’re trying to yell through all of these barriers and try to show them with your eyes that you’re here and you’re not going to leave them and will take care of them,” she said. “But yet you’re panicking inside completely that you’re going to get this disease and you’re going to be the one in the bed or a family member that you love, take it home to them.”

When asked if hospital leaders had seen signs of strain among the nursing staff or were concerned about their resilience headed into the winter months, a St. Vincent spokesperson wrote in a brief statement that during the pandemic “we have prioritized the safety and well-being of our staff, and we remain focused on that.”

Nationally, the viral risk to clinicians has been well documented. From March 1 through May 31, were health care workers, one-third of them in nursing-related occupations, according to data published last month by the Centers for Disease Control and Prevention.

As cases mount in the winter months, moral injury researcher Dean said, “nurses are going to do the calculation and say, ‘This risk isn’t worth it.’”

Juliano Innocenti, a traveling nurse working in the San Francisco area, decided to take off for a few months and will focus on wrapping up his nurse practitioner degree instead. Since April, he’s been seeing a therapist “to navigate my powerlessness in all of this.”

Innocenti, 41, has not been on the front lines in a hospital battling COVID-19, but he still feels the stress because he has been treating the public at an outpatient dialysis clinic and a psychiatric hospital and seen administrative problems generated by the crisis. He pointed to issues such as inadequate personal protective equipment.

Innocenti said he was concerned about “the lack of planning and just blatant disregard for the basic safety of patients and staff.” Profit motives too often drive decisions, he suggested. “That’s what I’m taking a break from.”

Building Resiliency

As cases surge again, hospital leaders need to think bigger than employee assistance programs to backstop their already depleted ranks of nurses, Dean said. Along with plenty of protective equipment, that includes helping them with everything from groceries to transportation, she said. Overstaff a bit, she suggested, so nurses can take a day off when they hit an emotional cliff.

The American Nurses Association, the American Association of Critical-Care Nurses (AACN) and several other nursing groups have with links to mental health programs as well as tips for getting through each pandemic workday.

Kiersten Henry, an AACN board member and nurse practitioner in the intensive care unit at MedStar Montgomery Medical Center in Olney, Maryland, said that the nurses and other clinicians there have started to gather for a quick huddle at the end of difficult shifts. Along with talking about what happened, they share several good things that also occurred that day.

“It doesn’t mean that you’re not taking it home with you,” Henry said, “but you’re actually verbally processing it to your peers.”

When cases reached their highest point of the spring in Massachusetts, Nester said there were some days she didn’t want to return.

“But you know that your friends are there,” she said. “And the only ones that really truly understand what’s going on are your co-workers. How can you leave them?”

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His monthly premium payment of $435 for family coverage is roughly the same as the insurance at his previous job. But the policy at his current job carries an annual deductible of $4,000, which he must pay out-of-pocket for his family’s care until he reaches that amount each year.

“Now everything is full price,” said the 53-year-old, who works at a warehouse just south of Dallas-Fort Worth. “That’s been a little bit of a struggle.”

To reduce his costs, Garza switched to a lower-cost diabetes medication, and he no longer wears a continuous glucose monitor to check his blood sugar. Since he started his job nearly two years ago, he said, his blood sugar levels have inched upward from an A1c of 7% or less, the target goal, to as high as 14% at his most recent doctor visit in November.

“My A1c is through the roof because I’m not on, technically, the right medication like before,” Garza said. “I’m having to take something that I can afford.”

Plans with high deductibles — the amount that patients must pay for most medical care before insurance starts pitching in — have become increasingly common. In 2024, participating in medical care plans were offered this type of insurance, up from 38% in 2015, according to federal data. Such plans are also offered through the Affordable Care Act marketplace.

With and many of the subsidies to help people pay for them poised to expire at year’s end, more people face tough choices as they weigh monthly premium costs against deductibles. To afford insurance at all, people may opt for a plan with low premium payments but with a high deductible, gambling that they won’t have any medical crises.

But high-deductible plans pose a particular challenge for those with chronic conditions, such as the who live with Type 1 or Type 2 diabetes. Adults with diabetes who are involuntarily switched to a high-deductible plan, compared with adults on other types of insurance, face an 11% higher risk of being hospitalized with a heart attack, a 15% higher risk of hospitalization for a stroke, and that they’ll go blind or develop end-stage kidney disease, according to a study published in 2024.

“All of these complications are preventable,” said , the study’s lead author.

Care vs. Cost

The initial rationale behind such high-deductible plans was to encourage people to become wiser health care shoppers, said McCoy, an associate professor of medicine at the University of Maryland School of Medicine in Baltimore. And they can be a good fit, proponents say, for people who don’t use a lot of medical care or who have cash on hand for a health crisis.

But while people with an excruciating earache will seek care, McCoy said, those with unhealthy blood sugar levels might not feel as urgent a need to seek treatment — despite the potential long-term damage — given the acute financial pain.

“You have no symptoms until it’s too late,” she said. “At that point, the damage is irreversible.”

Overall, medical care for people with diabetes costs insurers and patients an average of the disease, according to an analysis. Type 2 diabetes, the more common form, is diagnosed when the body can no longer process or produce enough insulin to adequately regulate blood sugars. With Type 1, the body can’t produce insulin. Those with the disease may end up on the financial hook not just for insulin and other types of medication but for related equipment.

Mallory Rogers, whose 6-year-old daughter, Adeline, has Type 1, calculates that it costs roughly $1,200 a month for insulin, a pump, and a continuous glucose monitor. That figure doesn’t include the cost of emergency supplies needed in case Adeline’s technology malfunctions. Those include another type of insulin, blood-testing strips, and a nasal spray that’s nearly $600 for a two-pack of vials — supplies that must be replaced once a year or more frequently.

“If she doesn’t have insulin, it would become an emergency situation within two hours,” said Rogers, a technology consultant who lives in Sanford, Florida. Rogers has been saving for the coming year when her daughter moves to the high-deductible health plan offered by Rogers’ employer, which has a $3,300 deductible for family coverage.

Taxing Decisions

Many insurance plans carry increasingly high deductibles. But to be defined as a high-deductible health plan — and thus be eligible to offer a health savings account — a plan’s deductible for 2026 must be , according to IRS rules.

Health savings accounts enable people to squirrel away money that can be rolled over from year to year to be used for eligible medical expenses, including prior to meeting a deductible. Such accounts, available through a plan or employer, can provide tax benefits. The contributions are limited to $4,400 individually and $8,750 for a family in 2026, and employers may contribute toward that total. Rogers’ employer pays $2,000 spread out over the year, and Garza’s contributes $1,200.

Rogers recognizes that she’s fortunate to have accumulated $7,000 so far in her health savings account to prepare for her daughter’s insurance shifting to Rogers’ plan.

“Adding a financial burden to an already very stressful medical condition, it hurts my heart,” she said, reflecting on those who can’t similarly stockpile. “Nobody asks to have diabetes, Type 1 or Type 2.”

The median deductible for employer health insurance plans was $2,750 in 2024, but deductibles can run $5,000 or higher, said George Huntley, CEO of both the and .

When deductibles are too high, Huntley said, routine maintenance is what patients skimp on: “You don’t take the drug that you’re supposed to take to maintain your blood glucose. You ration your insulin, if that’s your scenario. You take pills every other day.”

Garza knows he should do more to control his blood sugar, but financial realities complicate the equation. His previous health plan covered a newer class of diabetes medication, called a GLP-1 agonist, for $25 a month. He wasn’t charged for his remaining medications, which included blood pressure and cholesterol drugs, or his continuous glucose monitor.

With his new insurance, he pays $125 monthly for insulin and several other medications. He doesn’t see his endocrinologist for checkups more than twice a year.

“He wants to see me every three months,” Garza said. “But I told him it’s not possible at $150 a pop.”

Plus, he typically needs lab testing before each visit, an additional $111.

In 2026, the deductible for a “silver”-level plan on the marketplace will average $5,304 without cost-sharing reductions, according to an analysis from KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News. For a . An annual visit and some preventive screenings, such as a mammogram, would be covered free of cost to the patient.

Moreover, people , whether through their employer or the marketplace, should figure out their annual out-of-pocket maximum, which still applies after the deductible is met, Huntley said.

Garza’s family policy requires him to pay 20% until he reaches $10,000, for example.

Given Garza’s high blood sugar levels, his doctor prescribed a fast-acting form of insulin to take as needed with meals, which costs an additional $79 monthly. He planned to fill it in December, when he’s responsible for only 20% of the cost after he has hit his deductible but not yet reached his out-of-pocket maximum.

Garza likes his job despite its health plan, saying he’s never missed a day of work, even recently when he had a stomach bug. As of late 2025, he remained conflicted about whether to sign up for health insurance when his company’s enrollment period rolls around in mid-2026.

He worries that dropping insurance would place his family too much at risk if a major medical crisis struck. Still, he pointed out, he could then use the money he now spends on monthly premiums to directly pay for care to better manage his diabetes.

“I’m just stuck, to be honest with you,” he said.

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Bynum, then in his second year of residency training as a family medicine physician, was wrapping up a long shift when he was called into an emergency delivery. To save the baby’s life, he used a vacuum device, which applies suction to assist with rapid delivery.

The baby emerged unharmed. But the mother suffered a severe vaginal tear that required surgical repair by an obstetrician. Soon afterward, Bynum retreated to an empty hospital room, trying to process his feelings about the unexpected complication.

“I didn’t want to see anybody. I didn’t want anybody to find me,” said Bynum, now an at Duke University School of Medicine in North Carolina. “It was a really primitive response.”

Shame is a common and highly uncomfortable human emotion. In the years since that pivotal incident, Bynum has become a among clinicians and researchers who argue that the intense crucible of medical training can amplify shame in future doctors.

He is now part of an emerging effort to teach what he describes as “” to medical school students and practicing physicians. While shame can’t be eliminated, Bynum and his research colleagues maintain that related skills and practices can be developed to reduce the culture of shame and foster a healthier way to engage with it.

Without this approach, they argue, tomorrow’s doctors won’t recognize and address the emotion in themselves and others. And thus, they risk transmitting it to their patients, even inadvertently, which may . Shaming patients can backfire, Bynum said, making them defensive and leading to isolation and sometimes substance use.

The U.S. political environment presents an additional obstacle. Health and Human Services Secretary Robert F. Kennedy Jr. and other top Trump administration health officials have autism, diabetes, attention-deficit/hyperactivity disorder, and other chronic issues in large part on the lifestyle choices of people with the conditions — or their parents. For instance, FDA Commissioner Marty Makary suggested in a Fox News interview that diabetes could be better treated with cooking classes than “.”

Even before the political shift, that attitude was reflected at doctors’ offices as well. A 2023 study found that when treating patients with Type 2 diabetes. About 44% viewed those patients as lacking motivation to make lifestyle changes, while 39% said they tended to be lazy.

“We don’t like feeling shame. We want to avoid it. It’s very uncomfortable,” said , a nurse at the University of Wisconsin-Madison, who has of related studies, published in 2024. And if the source of shame is from the clinician, the patient may ask, “‘Why would I go back?’ In some cases, that patient may generalize that to the whole health care system.”

Indeed, Christa Reed dropped out of regular medical care for two decades, weary of weight-related lectures. “I was told when I was pregnant that my morning sickness was because I was a plus-size, overweight woman,” she said.

Except for a few urgent medical issues, such as an infected cut, Reed avoided health care providers. “Because going into a doctor for an annual visit would be pointless,” said the now 45-year-old Minneapolis-area wedding photographer. “They would only just tell me to lose weight.”

Then, last year, severe jaw pain drove Reed to seek specialty care. A routine blood pressure check showed a sky-high reading, sending her to the emergency room. “They said, ‘We don’t know how you’re walking around normal,’” she recounted.

Since then, Reed has found supportive physicians with expertise in nutrition. Her blood pressure remains under control with medication. She’s also nearly 100 pounds below her heaviest weight, and she hikes, bikes, and lifts weights to build muscle.

, a California psychiatrist, is among a group of physicians trying to bring attention to the detrimental effects of shame and develop strategies to prevent and mitigate it. While this effort is in the early stages, she co-led a session on the spiral of shame at the American Psychiatric Association’s annual meeting in May.

If physicians don’t acknowledge shame in themselves, they can be at risk of depression, , sleeping difficulties, and other ripple effects that erode patient care, she said.

“We often don’t talk about how important the human connection is in medicine,” Woodward said. “But if your doctor is burned out or feeling like they don’t deserve to be your doctor, patients feel that. They can tell.”

In a survey conducted this year, 37% of graduating students at some point in medical school. And nearly 20% described public humiliation, according to the annual survey by the Association of American Medical Colleges.

Medical students and resident physicians are already prone to perfectionism, along with an almost “masochistic” work ethic, as Woodward described it. Then they’re run through a gantlet of exams and years of training, amid constant scrutiny and with patients’ lives on the line.

During training, physicians work in teams and make presentations to teaching faculty about a patient’s medical issues and their recommended treatment approach. “You trip over your words. You miss things. You get things out of order. You go blank,” Bynum said. And then shame creeps in, he said, leading to other debilitating thoughts, such as “‘I’m no good at this. I’m an idiot. Everyone around me would have done this so much better.’”

Yet shame remains “a crack in your armor that you don’t want to show,” said , a family medicine physician at the University of Utah who has taught medical students about the potential for shame as part of a broader ethics and humanities course.

“You’re taking care of a human life,” she said. “Heaven forbid that you act like you’re not capable or you show fear.”

When students are taught about shame, the goal is to help future physicians recognize the emotion in themselves and others, so they don’t perpetuate the cycle, Pippitt said. “If you felt shamed throughout your medical education, it normalizes that as the experience,” she said.

Above all, physicians-in-training can work to reframe their mindset when they receive a poor grade or struggle to master a new skill, said Woodward, the California psychiatrist. Instead of believing that they’ve failed as a physician, they can focus on what they got wrong and ways to improve.

Last year, Bynum started teaching Duke physicians about shame competence, beginning with roughly 20 OB-GYN residents. This year, he launched a larger initiative with , a research and training partnership between Duke University and the University of Exeter in England that he co-founded, to reach about 300 people across Duke’s Department of Family Medicine and Community Health, including faculty and residents.

This sort of training is rare among Duke OB-GYN resident ’s peers in other programs. Dancel, who completed the training, now strives to support students as they learn skills such as how to suture. She hopes they will pay that approach forward in “a chain reaction of being kind to each other.”

More than a decade after Bynum experienced that stressful emergency delivery, he still regrets that shame kept him from checking on the mother as he usually would following delivery. “I was too scared of how she was going to react to me,” he said.

“It was a little devastating,” he said, when a colleague later told him that the mother wished he had stopped by. “She had passed a message along to thank me for saving her baby’s life. If I had just given myself a chance to hear that, that would have really helped in my recovery, to be forgiven.”

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After the 36-year-old was diagnosed with stage 3 breast cancer in December, she learned that there weren’t any cancer services in her community of Del Rio, a town of 35,000 near the Texas-Mexico border.

To get treatment, she and her husband, Manuel, must drive nearly three hours east to San Antonio. So they set an alarm for 4 a.m., which allows for just enough time to roll out of bed, brush their teeth, and begin the long drive navigating dark roads while watching for deer.

About an hour before they arrive at the cancer clinic, the couple pulls over to quickly eat fast food in the car. The break gives Herlinda time to apply ointment on the port where the needle for her chemotherapy will be inserted.

“It numbs the area, so when I get to the infusion room the needle won’t hurt,” she said.

For rural patients, getting cancer treatment close to home has always been difficult. But in recent years, chemotherapy deserts have expanded across the United States, with 382 rural from 2014 to 2022, according to a report published this year by Chartis, a health analytics and consulting firm.

Texas led that list, with 57 rural hospitals — nearly half of those statewide that had offered chemotherapy — cutting the service by 2022, according to the analysis. Rural hospitals in states like Texas, which hasn’t expanded Medicaid, have been more likely to close, according to data from the Cecil G. Sheps Center for Health Services Research.

To keep the doors open, in small communities nationwide continue to shed basic health care services, like obstetrics and chemotherapy, said Michael Topchik, executive director of the Chartis Center for Rural Health.

“The data are staggering,” Topchik said. “Can you imagine feeling that sick, and having to drive an hour in each direction, or maybe more each direction, several times a week?”

Loss of chemotherapy services can signal other gaps in cancer care, such as a shortage of local specialty physicians and nurses, which is bad news for patients, said Marquita Lewis-Thames, an assistant professor at Northwestern University in Chicago whose research covers rural cancer care.

Rural patients are less likely to survive at least five years after a cancer diagnosis compared with their urban counterparts, concluded a and published in JAMA Network Open in 2022. While the rural-urban survival gap narrowed over the nearly 40 years researchers studied, the disparity persisted across most racial and ethnic groups, with only a few exceptions, she said.

Many cancer drugs are now given orally and can be taken at home, but some treatments for breast, colon, and other common cancers must still be administered intravenously inside a medical facility. Even distances of an hour or two each way can strain patients who already may be coping with nausea, diarrhea, and other side effects, physicians and patient advocates said.

“It’s pretty uncomfortable for some of these patients who may have bone metastases or have significant muscular pain and have to sit in the car that long and hit road bumps,” said Shivum Agarwal, a family physician who practices in rural communities an hour west of Fort Worth, Texas.

Plus, travel can cost much more than filling the gas tank.

“Usually it requires an able-bodied family member taking off a whole day or at least half a day from work,” Agarwal said. “So, there’s a big economic cost for the family.”

In this sense, the Sanchez family is fortunate. Herlinda’s mother drives four hours from Abilene to Del Rio to watch the couple’s youngest children, their 2-year-old twins.

Cancer infusions can last as long as eight hours on top of the travel time, causing significant financial and logistical challenges, said Erin Ercoline, executive director of the San Antonio-based ThriveWell Cancer Foundation. The nonprofit provides adult patients with financial assistance, including for gaps in insurance and transportation-related costs. It has helped cover gasoline for Sanchez, who received her final round of chemotherapy in late June. The financial assistance will also pay for her hotel when she travels for breast surgery this month.

Not all rural hospitals are ending chemotherapy. Childress Regional Medical Center, a 39-bed hospital in West Texas, is constructing a 6,000-square-foot center for patients who need infusions for cancer and other diagnoses, including multiple sclerosis and rheumatology.

The infusion area, which started with two chairs in 2013 and now has four, will grow to 10 chairs and have more patient privacy when it opens next year. The next-nearest infusion center in this sprawling region is an hour or more away, which discourages some patients from seeking care, said Childress’ CEO, Holly Holcomb.

“We’ve had a handful of patients say, ‘If you can’t do it here, I’m not doing it,’” Holcomb said. She credits the federal 340B drug discount program for enabling the remote hospital to provide infusion drugs.

Hospitals that qualify for 340B can buy outpatient drugs at steep discounts. The program provides “a huge kickstand for rural hospitals,” said Topchik, of Chartis Center. Hospitals can use the savings to buoy or expand services provided to the community, he said.

But some patients are not daunted by long drives and travel costs.

“I’m from the country, so small is better — it’s just more personable,” said Dennis Woodward, 69, who lives in Woodson, Texas. He has a type of non-Hodgkin lymphoma and chooses to make a two-hour drive to Childress. He had first visited an oncology clinic in Abilene about an hour away. The clinicians were nice, but “I felt like a number,” he said.

After his first appointment at Childress this year, his oncologist, Fred Hardwicke, walked him over to meet the nurses who would administer the medicine, Woodward recalled.

Most Fridays during Herlinda Sanchez’s chemotherapy, Manuel would nap in the car. But during her final treatment in June, he stayed nearby, counting down the hours.

Several family members joined Herlinda when she rang the bell later that afternoon to signal the end of her treatment.

“I don’t want to be in San Antonio no more,” said Herlinda, a mother of four who does administrative work at Laughlin Air Force Base near Del Rio. “I’m looking forward to the break.”

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“I remember that drive home, bringing her back home, and we basically cried,” said the internal medicine physician, who had started practicing in eastern Kentucky near his childhood home shortly before his mother began feeling ill. “Nobody wants to get told they’ve got inoperable lung cancer. I cried because I knew what this meant for her.”

Now Stumbo, whose mother died the following year, in 1997, is among a group of Kentucky clinicians and researchers determined to rewrite the script for other families by promoting training and boosting awareness about early detection in the state with the highest lung cancer death rate. For the past decade, Kentucky researchers have promoted lung cancer screening, first recommended by the U.S. Preventive Services Task Force in 2013. These days the Bluegrass State screens more residents who are at high risk of developing lung cancer than any state except Massachusetts — 10.6% of eligible residents in 2022, more than double the national rate of 4.5% — according to the most recent American Lung Association analysis.

The effort has been driven by a research initiative called the , which in 2014 launched to improve screening and prevention, to identify more tumors earlier, when survival odds are far better. The group has worked with clinicians and hospital administrators statewide to boost screening rates both in urban areas and regions far removed from academic medical centers, such as rural Appalachia. But, a decade into the program, the researchers face an ongoing challenge as they encourage more people to get tested, namely the fear and stigma that swirl around smoking and lung cancer.

Lung cancer kills more Americans than any other malignancy, and the death rates are worst in a swath of states including Kentucky and its neighbors Tennessee and West Virginia, and stretching south to Mississippi and Louisiana, from the Centers for Disease Control and Prevention.

It’s a bit early to see the impact on lung cancer deaths because people may still live for years with a malignancy, LEADS researchers said. Plus, treatment improvements and other factors may also help reduce death rates along with increased screening. Still, data already shows that more cancers in Kentucky are being detected before they become advanced, and thus more difficult to treat, they said. Of total lung cancer cases statewide, the percentage of advanced cases — defined as cancers that had spread to the lymph nodes or beyond — hovered near 81% between 2000 and 2014, according to Kentucky Cancer Registry data. By 2020, that number had declined to 72%, according to the most recent data available.

“We are changing the story of families. And there is hope where there has not been hope before,” said Jennifer Knight, a LEADS principal investigator.

Older adults in their 60s and 70s can hold a particularly bleak view of their mortality odds, given what their loved ones experienced before screening became available, said Ashley Shemwell, a nurse navigator for the lung cancer screening program at Owensboro Health, a nonprofit health system that serves Kentucky and Indiana.

“A lot of them will say, ‘It doesn’t matter if I get lung cancer or not because it’s going to kill me. So I don’t want to know,’” said Shemwell. “With that generation, they saw a lot of lung cancers and a lot of deaths. And it was terrible deaths because they were stage 4 lung cancers.” But she reminds them that lung cancer is much more treatable if caught before it spreads.

The collaborative works with several partners, including the University of Kentucky, the University of Louisville, and GO2 for Lung Cancer, and has received grant funding from the Bristol Myers Squibb Foundation. Leaders have provided training and other support to 10 hospital-based screening programs, including a stipend to pay for resources such as educational materials or a nurse navigator, Knight said. In 2022, state lawmakers established a statewide lung cancer screening program based in part on the group’s work.

Jacob Sands, a lung cancer physician at Boston’s Dana-Farber Cancer Institute, credits the LEADS collaborative with encouraging patients to return for annual screening and follow-up testing for any suspicious nodules. “What the Kentucky LEADS program is doing is fantastic, and that is how you really move the needle in implementing lung screening on a larger scale,” said Sands, who isn’t affiliated with the Kentucky program and serves as a volunteer spokesperson for the American Lung Association.

In 2014, Kentucky expanded Medicaid, increasing the number of lower-income people who qualified for lung cancer screening and any related treatment. Adults 50 to 80 years old are advised to get a CT scan every year if they have accumulated at least 20 pack years and still smoke or have quit within the past 15 years, according to the latest task force recommendation, which widened the pool of eligible adults. (To calculate pack years, multiply the packs of cigarettes smoked daily by years of smoking.) The lung association offers an online quiz, called “,” to figure out likely eligibility for insurance coverage.

Half of U.S. patients aren’t diagnosed until their cancer has spread beyond the lungs and lymph nodes to elsewhere in the body. By then, the five-year survival rate is 8.2%.

But regular screening boosts those odds. When a CT scan detects lung cancer early, patients have an 81% chance of living at least 20 years, according to data published in November in the journal Radiology.

Some adults, like Lisa Ayers, didn’t realize lung cancer screening was an option. Her family doctor recommended a CT scan last year after she reported breathing difficulties. Ayers, who lives in Ohio near the Kentucky border, got screened at UK King’s Daughters, a hospital in far eastern Kentucky. The scan didn’t take much time, and she didn’t have to undress, the 57-year-old said. “It took me longer to park,” she quipped.

She was diagnosed with a lung carcinoid tumor, a type of neuroendocrine cancer that can grow in various parts of the body. Her cancer was considered too risky for surgery, Ayers said. A biopsy showed the cancer was slow-growing, and her doctors said they would monitor it closely.

Ayers, a lifelong smoker, recalled her doctor said that her type of cancer isn’t typically linked to smoking. But she quit anyway, feeling like she’d been given a second chance to avoid developing a smoking-related cancer. “It was a big wake-up call for me.”

Adults with a smoking history often report being treated poorly by medical professionals, said Jamie Studts, a health psychologist and a LEADS principal investigator, who has been involved with the research from the start. The goal is to avoid stigmatizing people and instead to build rapport, meeting them where they are that day, he said.

“If someone tells us that they’re not ready to quit smoking but they want to have lung cancer screening, awesome; we’d love to help,” Studts said. “You know what? You actually develop a relationship with an individual by accepting, ‘No.’”

Nationally, screening rates vary widely. Massachusetts reaches 11.9% of eligible residents, while California ranks last, screening just 0.7%, according to the lung association analysis.

That data likely doesn’t capture all California screenings, as it may not include CT scans done through large managed care organizations, said Raquel Arias, a Los Angeles-based associate director of state partnerships at the American Cancer Society. She cited other 2022 data for California, looking at lung cancer screening for eligible Medicare fee-for-service patients, which found a screening rate of 1%-2% in that population.

But, Arias said, the state’s effort is “nowhere near what it needs to be.”

The low smoking rate in California, along with its image as a healthy state, “seems to have come with the unintended consequence of further stigmatizing people who smoke,” said Arias, citing one of the findings from a 2022 report looking at lung cancer screening barriers. For instance, eligible patients may be reluctant to share prior smoking habits with their health provider, she said.

Meanwhile, Kentucky screening efforts progress, scan by scan.

At Appalachian Regional Healthcare, 3,071 patients were screened in 2023, compared with 372 in 2017. “We’re just scratching the surface of the potential lives that we can have an effect on,” said Stumbo, a lung cancer screening champion at the health system, which includes 14 hospitals, most located in eastern Kentucky.

The doctor hasn’t shed his own grief about what his family missed after his mother died at age 51, long before annual screening was recommended. “Knowing that my children were born, and never knowing their grandmother,” he said, “just how sad is that?”

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By then, the reddish area along her hairline had grown from a 2-inch circle to cover nearly her entire forehead. It oozed fluid and was painful.

“Honestly, I was just waiting on it to kill me, because I thought that’s what was going to have to happen,” said the 41-year-old mother of three, who lives in Easley, South Carolina.

Adcox had first met with physicians at the academic medical center in late 2020, after a biopsy diagnosed basal cell carcinoma. The operation to remove the cancer would require several physicians, she was told, including a neurosurgeon, because of how close it was to her brain.

But Adcox was uninsured. She had lost her automotive plant job in the early days of the pandemic, and at the time of her diagnosis was equally panicked about the complex surgery and the prospect of a hefty bill. Instead of proceeding with treatment, she attempted to camouflage the expanding cancerous area for more than a year with hats and long bangs.

If Adcox had developed breast or cervical cancer, she likely would have qualified for insurance coverage under a federal law that extends Medicaid eligibility to lower-income patients diagnosed with those two malignancies. For female patients with other types of cancer, as well as pretty much all male patients, the options are scant, especially in that haven’t yet implemented Medicaid expansion, according to cancer physicians and health policy experts who study access to care.

In the face of potentially daunting bills, uninsured adults sometimes delay care, which can result in worse survival outcomes, . The odds of patients getting insurance to help cover the cost of treatment play out a bit like a game of roulette, depending upon where they live and what type of cancer they have.

“It is very random — that’s, I think, the heartbreaking part about it,” said Dr. Evan Graboyes, a head and neck surgeon and one of Adcox’s physicians. “Whether you live or die from cancer shouldn’t really be related to what state you live in.”

The Affordable Care Act gave states the option to expand Medicaid eligibility and cover more people. Shortly after the law passed, with a new cancer diagnosis lacked insurance in Medicaid expansion states versus 7.8% in nonexpansion states, according to a study published in JAMA Oncology in 2018. Researchers at the American Cancer Society, who conducted the analysis, estimate that about 30,000 uninsured people are diagnosed with cancer each year.

But in all states, lower-income uninsured patients with breast or cervical cancer may have another route for coverage, even if they don’t otherwise qualify for Medicaid. Adults with cancer detected through the can enroll in Medicaid for the duration of their cancer treatment, as a result of advocacy efforts and federal legislation that started more than three decades ago.

In 2019, 43,549 breast and cervical cancer patients were enrolled, according to a published in 2020.

“If you’re lucky to be diagnosed with breast or cervical cancer, you’re good,” said Dr. Fumiko Chino, a radiation oncologist at Memorial Sloan Kettering Cancer Center in New York City, who studies cancer treatment access and affordability. “But otherwise, you may have some significant obstacles.”

The total amount billed to the insurer during the year following a cancer diagnosis can be steep. For instance, costs in 2016 averaged , according to a 2022 study that calculated insurance claims for several common malignancies diagnosed in privately insured patients.

Since uninsured adults can struggle to afford preventive care, their cancer may not be identified until it’s more advanced, making it costlier for the patient and the health system, said Robin Yabroff, an author of the study in JAMA Oncology and a scientific vice president at the American Cancer Society.

Patients who can’t get financial assistance through a safety-net facility sometimes rack up medical debt, use credit cards, or launch fundraising efforts though online sites, Yabroff said. “We hear stories of people who mortgage their homes to pay for cancer treatment.”

Cancer patients can purchase insurance through the ACA health insurance marketplace. But they often must wait until the regular enrollment period near the end of the year, and those health plans don’t become effective until the start of the next calendar year.

That’s because the federal law was designed to encourage people to sign up when they are healthy, which helps control costs, said MaryBeth Musumeci, an associate teaching professor of health policy and management at George Washington University in Washington, D.C. If a new diagnosis were a qualifying event for new coverage, she said, “then it would incentivize people to stay uninsured while they were healthy and they didn’t think they really were going to need coverage.”

Meanwhile, the on-ramp to Medicaid coverage for lower-income patients with breast and cervical cancer is a story of successful advocacy, dating to a that created the national breast and cervical screening program. Mammography started to be , and advocacy groups pushed to reach more underserved individuals, said Katie McMahon, a policy principal at the American Cancer Society Cancer Action Network, the organization’s advocacy arm.

But research showed that some uninsured adults struggled to get care for those cancers detected through the screening program, McMahon said. A 2000 law to them, and by 2008 all 50 states and the District of Columbia had done so, according to the 2020 GAO report.

For other cancer patients, one of the remaining avenues to coverage, according to Chino, is to qualify for disability through the Social Security Administration, after which they can apply for Medicaid. The federal agency has a for cancer patients. It also has a , which offers faster reviews for patients with certain serious medical conditions, including advanced or aggressive cancers.

Although the rules vary, many patients don’t qualify until their disease has spread or the cancer requires at least a year of intense treatment, Chino said. That presents an inherent catch-22 for people who are uninsured but have curable types of cancer, she said.

“To qualify for Medicaid, I have to wait for my cancer to be incurable,” she said, “which is very depressing.”

For example, the Compassionate Allowances program doesn’t list basal cell carcinoma, and it covers head and neck cancer only if it has spread elsewhere in the body or can’t be removed surgically.

Adcox said that before her 12-hour operation last June, her financial assistance application with the Medical University of South Carolina was still pending. Someone from the hospital, she recalled, estimated the bill would be $176,000 and asked how much Adcox could put down. She cobbled together $700 with the help of loved ones.

But she did qualify for financial assistance and hasn’t received any bills, except from an outside lab services provider. “It’s over,” Adcox said. She’s since undergone radiation and will have more reconstructive surgeries. But she’s cancer-free. “It didn’t kill me. It didn’t kill me.”

Still, not everyone finds a safety net.

Brian Becker, of El Paso, Texas, was uninsured and not working when he learned he had chronic myelogenous leukemia in summer 2021, said Stephanie Gamboa, his ex-wife and the mother of their young daughter. His cancer physician required an upfront payment, she said, and it took several months to borrow enough money.

He started chemotherapy the following year, and over months lost weight and became weaker, returning to the emergency room with infections and worsening kidney function, Gamboa said. The last time their daughter saw her father, “he couldn’t get out of bed. He was literally skin and bones,” Gamboa said.

Becker started the process to request disability benefits. The text he sent Gamboa, which she shared with KHN, stated that review of his application began in June 2022 and was expected to take six months.

The denial letter, dated Feb. 4, 2023, arrived more than a month after at age 32. It read in part: “Based on a review of your medical conditions, you do not qualify for benefits on this claim.”

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Cancer coincides with roughly 1 in 1,000 pregnancies, most frequently breast cancer, melanoma, cervical cancer, lymphomas, and leukemias. But medications and other treatments can be toxic to the developing fetus or cause birth defects. In some cases, hormones that are supercharged during pregnancy fuel the cancer’s growth, putting the patient at greater risk.

Although new abortion restrictions often allow exceptions based on “medical emergency” or a “life-threatening physical condition,” cancer physicians describe the legal terms as unclear. They fear misinterpreting the laws and being left in the lurch.

For instance, brain cancer patients have traditionally been offered the option of abortion if a pregnancy might limit or delay surgery, radiation, or other treatment, said Dr. Edjah Nduom, a brain cancer surgeon at Emory University’s Winship Cancer Institute in Atlanta.

“Is that a medical emergency that necessitates the abortion? I don’t know,” Nduom asked, trying to parse the medical emergency exception . “Then you end up in a situation where you have an overzealous prosecutor who is saying, ‘Hey, this patient had a medical abortion; why did you need to do that?’” he said.

Pregnant patients with cancer should be treated similarly to non-pregnant patients when feasible, though sometimes adjustments are made in the timing of surgery and other care, according to , published in 2020 in Current Oncology Reports.

With breast cancer patients, surgery could be performed early on as part of the treatment, pushing chemotherapy to later in the pregnancy, according to the research. Cancer experts typically recommend avoiding radiation therapy throughout pregnancy, and most chemotherapy drugs during the first trimester.

But with some cancers, such as acute leukemia, the recommended drugs have known toxic risks to the fetus, and time is not on the patient’s side, said Dr. Gwen Nichols, chief medical officer of the Leukemia & Lymphoma Society.

“You need treatment urgently,” she said. “You can’t wait three months or six months to complete a pregnancy.”

Another life-threatening scenario involves a patient early in her pregnancy who has been diagnosed with breast cancer that’s spreading, and tests show that the cancer’s growth is spurred by the hormone estrogen, said Dr. Debra Patt, an oncologist in Austin, Texas, who estimated she has cared for more than two dozen pregnant patients with breast cancer.

“Pregnancy is a state where you have increased levels of estrogen. It’s actually actively at every moment causing the cancer to grow more. So I would consider that an emergency,” said Patt, who is also executive vice president over policy and strategic initiatives at Texas Oncology, a statewide practice with more than 500 physicians.

When cancer strikes individuals of child-bearing age, one challenge is that malignancies tend to be more aggressive, said Dr. Miriam Atkins, an oncologist in Augusta, Georgia. Another is that it’s unknown whether some of the newer cancer drugs will affect the fetus, she said.

While hospital ethics committees might be consulted about a particular treatment dilemma, it’s the facility’s legal interpretation of a state’s abortion law that will likely prevail, said Micah Hester, an expert on ethics committees who chairs the department of medical humanities and bioethics at the University of Arkansas for Medical Sciences College of Medicine in Little Rock.

“Let’s be honest,” he said. “The legal landscape sets pretty strong parameters in many states on what you can and cannot do.”

It’s difficult to fully assess how physicians plan to handle such dilemmas and discussions in states with near-total abortion bans. Several large medical centers contacted for this article said their physicians were not interested or not available to speak on the subject.

Other physicians, including Nduom and Atkins, said the new laws won’t alter their discussions with patients about the best treatment approach, the potential impact of pregnancy, or whether abortion is an option.

“I’m going to always be honest with patients,” Atkins said. “Oncology drugs are dangerous. There are some drugs that you can give to [pregnant] cancer patients; there are many that you cannot.”

The bottom line, maintain some, is that termination remains a critical and legal part of care when cancer threatens someone’s life.

Patients “are counseled on the best treatment options for them, and the potential impacts on their pregnancies and future fertility,” Dr. Joseph Biggio Jr., chair of maternal-fetal medicine at Ochsner Health System in New Orleans, wrote in an email. “Under state laws, pregnancy termination to save the life of the mother is legal.”

Similarly, Patt said that physicians in Texas can counsel pregnant patients with cancer about the procedure if, for instance, treatments carry documented risks of birth defects. Thus, physicians can’t recommend them, and abortion can be offered, she said.

“I don’t think it’s controversial in any way,” Patt said. “Cancer left unabated can pose serious risks to life.”

Patt has been educating physicians at Texas Oncology on , as well as sharing a JAMA Internal Medicine editorial that . “I feel pretty strongly about this, that knowledge is power,” she said.

Still, the Texas law’s vague terminology complicates physicians’ ability to determine what’s legally permissible care, said Joanna Grossman, a professor at SMU Dedman School of Law. She said nothing in the statute tells a doctor “how much risk there needs to be before we label this legally ‘life-threatening.’”

And if a woman can’t obtain an abortion through legal means, she has “grim options,” according to Hester, the medical ethicist. She’ll have to sort through questions like: “Is it best for her to get the cancer treatment on the time scale recommended by medicine,” he said, “or to delay that cancer treatment in order to maximize the health benefits to the fetus?”

Getting an abortion outside Georgia might not be possible for patients with limited cash or no backup child care or who share one car with an extended family, Atkins said. “I have many patients who can barely travel to get their chemotherapy.”

Dr. Charles Brown, a maternal-fetal medicine physician in Austin who retired this year, said he can speak more freely than practicing colleagues. The scenarios and related unanswered questions are almost too numerous to count, said Brown, who has cared for pregnant women with cancer.

Take as another example, he said, a potential situation in a state that incorporates “fetal personhood” in its law, such as Georgia. What if a patient with cancer can’t get an abortion, Brown asked, and the treatment has known toxic effects?

“What if she says, ‘Well, I don’t want to delay my treatment — give me the medicine anyway,’” Brown said. “And we know that medicine can harm the fetus. Am I now liable for harm to the fetus because it’s a person?”

Whenever possible, physicians have always strived to treat the patient’s cancer and preserve the pregnancy, Brown said. When those goals conflict, he said, “these are gut-wrenching trade-offs that these pregnant women have to make.” If termination is off the table, “you’ve removed one of the options to manage her disease.”

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As the Supreme Court appears poised to return abortion regulation to the states, recent experience in Texas illustrates that medical care for miscarriages and dangerous ectopic pregnancies would also be threatened if restrictions become more widespread.

One passed last year lists several medications as abortion-inducing drugs and largely bars their use for abortion after the seventh week of pregnancy. But two of those drugs, misoprostol and mifepristone, are the only drugs recommended in the American College of Obstetricians and Gynecologists guidelines for treating a patient after an early pregnancy loss. The other miscarriage treatment is a procedure described as surgical uterine evacuation to remove the pregnancy tissue — the same approach as for an abortion.

“The challenge is that the treatment for an abortion and the treatment for a miscarriage are exactly the same,” said Dr. , a professor of obstetrics and gynecology at the University of Washington in Seattle and an expert in early pregnancy loss.

Miscarriages occur in roughly 1 out of 10 pregnancies. Some people experience loss of pregnancy at home and don’t require additional care, other than emotional support, said Dr. , who chairs the OB-GYN department at the University of Texas-Rio Grande Valley School of Medicine. But in other situations, he said, providers may need to intervene to stop bleeding and make sure no pregnancy tissue remains, as a guard against infection.

Dr. , an OB-GYN and assistant professor at the Dell Medical School at the University of Texas-Austin, has already heard about local patients who have been miscarrying, and couldn’t get a pharmacy to fill their misoprostol prescription. “The pharmacy has said, ‘We don’t know whether or not you might be using this medication for the purposes of abortion,’” she said.

Thaxton, who supervises the obstetrics-gynecology residents who have seen these patients, said sometimes the prescribing clinic will intervene, but it takes the patient longer to get the medication. Other times patients don’t report the problem and miscarry on their own, she said, but without medication they risk additional bleeding.

Under another new Texas abortion law, someone who “aids or abets” an abortion after cardiac activity can be detected, typically around six weeks, can be subject to at least a $10,000 fine per occurrence. Anyone can bring that civil action, posing a quandary for physicians and other providers. How do they follow the latest guidelines when other people — from medical professionals to friends and family members — can question their intent: Are they helping care for a miscarriage or facilitating an abortion?

Sometimes patients don’t realize that they have lost the pregnancy until they come in for a checkup and no cardiac activity can be detected, said Dr. Emily Briggs, a family physician who delivers babies in New Braunfels, Texas. At that point, the patient can opt to wait until the bleeding starts and the pregnancy tissue is naturally released, Briggs said. For some, that’s too difficult, given the emotions surrounding the pregnancy loss, she said. Instead, the patient may choose medication or a surgical evacuation procedure, which Briggs said may prove necessary anyway to avoid a patient becoming septic if some of the tissue remains in the uterus.

But now in Texas, the new laws are creating uncertainties that may deter some doctors and other providers from offering optimal miscarriage treatment.

These situations can create significant moral distress for patients and providers, said , a bioethicist and assistant professor of medical education at the University of North Texas Health Science Center in Fort Worth. “Any law that creates a hesitancy for physicians to uphold the standard of care for a patient has a cascade of harmful effects both for the patient but also for everyone else,” said Esplin.

It’s an emotional and legal dilemma that potentially faces not just obstetricians and midwives, but also family physicians, emergency physicians, pharmacists, and anyone else who might become involved with pregnancy care. And Ogburn, who noted that he was speaking personally and not for the medical school, worries that fears about the Texas laws have already delayed care.

“I wouldn’t say this is true for our practice,” he said. “But I have certainly heard discussion among physicians that they’re very hesitant to do any kind of intervention until they’re absolutely certain that this is not possibly a viable pregnancy — even though the amount of bleeding would warrant intervening because it’s a threat to the mother’s life.”

John Seago, legislative director for , described this type of hesitation as “an awful misunderstanding of the law.” Even before the passage of the two bills, existing Texas law stated that the act is not an abortion if it involves the treatment of an ectopic pregnancy — which most commonly occurs when the pregnancy grows in the fallopian tube — or to “remove a dead, unborn child whose death was caused by spontaneous abortion,” he said, pointing to the statute. Another area of Texas law that Seago cited provides an exception to the state’s abortion restrictions if the mother’s life is in danger or she’s at “serious risk of substantial impairment of a major bodily function” unless an abortion is performed.

“It is a pro-life position to allow physicians to make those life-and-death decisions,” Seago said. “And that may mean in certain circumstances protecting the mother in this situation and the child passing away.”

But interpretation of the laws is still causing challenges to care. At least several OB-GYNs in the Austin area received a letter from a pharmacy in late 2021 saying it would no longer fill the drug methotrexate in the case of ectopic pregnancy, citing the recent Texas laws, said Dr. Charlie Brown, an Austin-based obstetrician-gynecologist who provided a copy to KHN. Methotrexate also is listed in the Texas law passed last year.

Ectopic pregnancy develops in an estimated 2% of reported pregnancies. Methotrexate or surgery are the only two options listed in the medical guidelines to prevent the fallopian tubes from rupturing and causing dangerous bleeding.

“Ectopic pregnancies can kill people,” said Brown, a district chair for the American College of Obstetricians and Gynecologists, representing Texas.

, a professor of law at Southern Methodist University’s Dedman School of Law in Dallas, understands why some in Texas’ pharmacy community might be nervous. “The penalties are quite draconian,” he said, noting that someone could be convicted of a felony.

However, Mayo said that his reading of the law allows for the use of methotrexate to treat an ectopic pregnancy. In addition, he said, other Texas laws and the Roe v. Wade decision provide an exception to permit abortion if a pregnant person’s life is in danger.

Since the Texas laws include a stipulation that there must be intent to induce an abortion, Mayo said that he’d advise physicians and other clinicians to closely document the rationale for medical care, whether it’s to treat a miscarriage or an ectopic pregnancy.

But Prager believes that the laws in Texas — and perhaps elsewhere soon — could boost physicians’ vulnerability to medical malpractice lawsuits. Consider the patient whose miscarriage care is delayed and develops a serious infection and other complications, Prager said. “And they decide to sue for malpractice,” she said. “They can absolutely do that.”

Texas providers are still adjusting to other ripple effects that affect patient care. Dr. Jennifer Liedtke, a family physician in Sweetwater, Texas, who delivers about 175 babies annually, no longer sends misoprostol prescriptions to the local Walmart. Since the new laws took effect, Liedtke said, the pharmacist a handful of times declined to provide the medication, citing the new law — despite Liedtke writing the prescription to treat a miscarriage. Walmart officials did not respond to multiple requests for comment.

Since pharmacists rotate through that Walmart, Liedtke decided to send those prescriptions to other pharmacies rather than attempt to sort out the misunderstanding anew each time.

“It’s hard to form a relationship to say, ‘Hey look, I’m not using this for an elective abortion,’” she said. “‘I’m just using this because this is not a viable pregnancy.’”

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The other question this debate hangs on: How few is too few births?

Consider the 11-bed Providence Valdez Medical Center, which brings 40 to 60 newborns into the world each year, according to Dr. John Cullen, one of several family physicians who deliver babies at the Valdez, Alaska, hospital. The next nearest obstetrics unit is a six- to seven-hour drive away, if ice and snow don’t make the roads treacherous, he said.

The hospital cross-trains its nurses so they can care for trauma and general medicine patients along with women in labor, and it invests in simulation training to keep their skills up, Cullen said. He typically stays on-site, checking regularly as labor progresses, just a few steps away if concerns arise.

If the measure is the number of deliveries, “I do think that obviously there’s too small and we’re probably at that limit of low volume,” Cullen said. “I don’t think that we really have a choice. So, we just have to be really good at what we do.”

Some researchers have raised concerns based on their findings that hospitals with few deliveries are more likely to experience problems with those births. Meanwhile, “maternity deserts” are becoming more common. From 2004 to 2014, 9% of rural U.S. counties lost all hospital obstetric services, leaving slightly more than half of rural counties without any, according to published in 2017 in the journal Health Affairs. Yet shutting down the obstetrics unit doesn’t stop babies from arriving, either in the emergency room or en route to the next closest hospital. In addition, women may have to travel farther for prenatal care if there’s no local maternity unit.

Clinician skills and confidence suffer without sufficient practice, said Dr. Nancy Dickey, a family physician and executive director of the Texas A&M [University] Rural and Community Health Institute in College Station. So, what is that minimum threshold for baby deliveries? “I don’t have a number for you,” she said.

Dickey and Cullen are not alone in their reluctance to set a metric. For instance, the American College of Obstetricians and Gynecologists has published a about steps that rural and other low-volume facilities can take to maintain clinician skills and patient safety, including conducting frequent drills and periodically rotating health providers to higher-volume facilities to gain experience. But when asked to define “low volume,” a spokesperson wrote in an email: “We intentionally don’t define a specific number for low-volume because we do not want to create an inaccurate misperception that less volume equals less quality.”

Neither does the American Academy of Family Physicians provide guidance on what constitutes too few deliveries for safe operation. The academy “has not specified a minimum of deliveries required to maintain high quality obstetrical care in rural and underserved communities due to the unique and multifaceted nature of each case in each community,” according to a written comment from the group’s president, Dr. Sterling Ransone Jr.

One challenge in sorting out any connection between the number of deliveries and safety is that the researchers use differing cutoffs for what qualifies as a hospital with a low number of births, said Katy Kozhimannil, a professor at the University of Minnesota School of Public Health who studies rural maternal health. Plus, such data-driven analyses don’t reflect local circumstances, she said. The income level of local women, their health risk factors, the distance to the closest hospital with an obstetrics unit, hospitals’ ability to keep trained doctors and nurses — hospital leaders must consider these and other factors as they watch their birth numbers fall due to declining local population or pregnant women opting to deliver at more urban high-tech hospitals, she said.

Research on birth volumes and outcomes has been mixed, but the “more consistent” finding is that hospitals with fewer deliveries are more likely to have complications, largely because of a lack of dedicated obstetric doctors and nurses, as well as potentially fewer resources for emergencies, such as blood banks, according to the authors of a on improving rural maternity care. A , published in 2015 in the American Journal of Obstetrics & Gynecology, found that women are three times as likely to hemorrhage after delivery in rural hospitals with the lowest number of deliveries — defined as between 50 and 599 annually — as in those with 1,700 or more.

Just 7.4% of U.S. babies are born at hospitals that handle 10 to 500 births annually, according to a published last month in JAMA Network Open. But those hospitals, which researchers described as low volume, are 37% of all U.S. hospitals that deliver babies.

Finances also influence these decisions, given that half of all rural births are paid for by Medicaid, which generally reimburses providers less than private insurance. Obstetrics is “referred to as a loss leader by hospital administrators,” Kozhimannil said. As births dwindle, it can become daunting to pay for clinicians and other resources to support a service that must be available 24/7, she said. “Most hospitals will operate in the red in their obstetrics for a very long time, but at some point it can become really difficult.”

If a hospital closes its unit, most likely fewer local women will get prenatal care, and conditions like a mother’s severe anemia or a baby’s breech position will be missed, Dickey said. “Not getting prenatal care increases the risks, wherever this patient delivers.”

One Texas A&M initiative will enable its family medicine residency program to use telemedicine and periodic in-person visits to get more prenatal care to pregnant women in rural Texas, Dickey said. “What we really want are healthy mamas and healthy babies,” she said.

The rural institute Dickey leads also plans to use a mobile unit to provide maternal simulation training to emergency room clinicians at 11 rural Texas hospitals, only three of which provide obstetrics. “But all of them catch babies now and then in their ER,” said Dickey.

In Valdez, Alaska, keeping the hospital’s unit open has paid off for residents in other ways, Cullen said. Since the hospital delivers babies, including by cesarean section, there’s work to support a nurse anesthetist in the community of slightly more than 4,000 people. That enables the hospital to handle trauma calls and, more recently, the complexities of treating covid-19 patients, he said.

In her ongoing research, Kozhimannil remains committed to nailing down a range at which deliveries have dropped low enough to signal that a hospital needs “either more resources or more training because safety could be at risk.” Not to shutter the obstetrics unit, she stressed. But rather to automatically qualify that hospital for more support, including extra financing through state and federal programs given that it’s taxpayers that foot the bill for delivery complications, she said.

Because women will keep getting pregnant, Kozhimannil said, even if a hospital or a doctor decides to stop providing obstetric services. “That risk does not go away,” she said. “It stays in the community. It stays with the people, especially those that are too poor to go other places.”

This <a target="_blank" href="/health-care-costs/how-low-can-they-go-rural-hospitals-weigh-keeping-obstetric-units-when-births-decline/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

That is, unless the baby’s arrival appears imminent, and the hospital’s unit is shut down at that point. In that case, a woman would deliver in the emergency room, said Dr. Jim Luecke, who has practiced 30-plus years in the area.

But that can be a tough call, he added. Luecke described his concerns for two patients, both nearing their due date, who had previously given birth, boosting the chance of a faster delivery. “They can go from 4 centimeters dilated to completely dilated within a few minutes,” said the family physician, who estimates he’s delivered 3,000 babies.

Some pregnant women already travel an hour and a half or longer to reach the 25-bed Big Bend Regional in Alpine, said Dr. Adrian Billings, another family physician who delivers babies there. “Now to divert these ambulances at least another 60 miles away, it’s asking for more deliveries to happen en route to the hospital, and potentially poor maternal or neonatal outcomes.”

Luecke can’t recall a time when the obstetrics unit at Big Bend Regional has closed.

But it’s happening in other parts of the state: Ten rural hospitals have stopped delivering babies in the past five years or so, leaving 65 out of 157 that still do, according to the Texas Organization of Rural & Community Hospitals.

Hiring and retaining rural nurses has become even more challenging amid the pandemic as nurses have been recruited to work in urban covid-19 hot spots and sometimes don’t return to their communities, said John Henderson, chief executive officer at TORCH. More recently, some Texas hospitals have offered signing bonuses of $10,000 or more as they jockey for nurses, he said. “Covid has caused a resetting of market rates and a reshuffling of nurse staffing.”

The circumstances at Big Bend Regional, which serves a 12,000-square-mile area (about the size of Maryland), illustrates the ripple effects of potentially losing obstetric services across a broader region. The hospital, owned by Quorum Health Corp., serves a swath that extends southwest to the Mexican border and includes Big Bend National Park as well as the communities of Presidio and Candelaria. The nearest hospital, the 25-bed Pecos County Memorial in Fort Stockton, is 68 miles northeast of Alpine.

As of late July, Big Bend Regional’s obstetrics services remained in flux, with the unit closed for four- and five-day stretches, said Billings. Physicians have been told that the unit would typically remain open only Monday morning through Thursday morning of each week until more nurses arrive, he said.

The staffing crisis highlights the need for more state and national efforts to train rural nurses and other clinicians, Billings added. “The big concern that I have is that, if we don’t fix this, this could be the beginning of a rural maternity care desert out here in the Big Bend.”

The hospital, which delivered 136 babies last year, said it is “working feverishly to ensure adequate staffing levels in the coming weeks,” recruiting to fill 10 nursing positions in the labor and delivery unit, according to a statement to KHN. “When our hospital is on diversion for elective OB patients, we communicate in advance with nearby emergency transport services and acute care providers to ensure continuity of care,” the statement said.

Kelly Jones of Alpine, who worried she was having contractions, couldn’t get anyone to pick up the phone for a few hours at Big Bend’s unit in mid-July. She decided to drop off her son at a friend’s house and head to the hospital.

Jones, who is nearly full term, knew the unit had been closed a few days earlier that month but didn’t realize that closures were still occurring. “I went in and said, ‘I think I’m in labor.’ They were like, ‘Well, you can’t go into labor and delivery because they’re closed. So we’re going to take you to the ER.’” In the end, medical personnel determined she wasn’t going to deliver that day and she went home.

Since the hospital first alerted doctors last month, the unit has been on diversion July 5-9, July 14-18 and then again July 22 until Sunday, July 25, according to Billings. Efforts were being made to recruit nurses from Odessa, 150 miles away, to fill in, but the outcome was uncertain, Billings said.

Luecke scheduled an induction for one patient for July 26, when her pregnancy would be at 39 weeks — a week short of full term — and the unit was scheduled to be open. “We are trying to induce them [women] on the days that they [the hospital’s unit] are open,” he said.

Jones, who is being cared for by another physician, is scheduled for induction Aug. 2, at 39 weeks. “For a while, I was not sleeping. I was really stressed. I was panicking about every scenario,” said the 30-year-old, whose pregnancy was initially considered high risk because her son had been born prematurely.

But Jones felt better once her induction date was set. And what if the baby arrives sooner and the unit is closed? She’s been told to go to the ER, to be taken from there by ambulance to the local airport and flown to Fort Stockton.

Malynda Richardson, director of emergency medical services for the town of Presidio, which sits along the Mexican border about 90 miles from Alpine, said its first responders transport more than two dozen women with pregnancy-related issues each year, most of them in labor, including an average of two who deliver en route. First responders, including paramedics, are not typically trained to assess a woman’s cervix for dilation, making it more difficult to gauge imminent delivery, she said.

Also, when responders drive an additional two to three hours round trip to reach Fort Stockton, that affects the Presidio community, which can reliably staff only one ambulance, Richardson said. “What happens when we do have that transport [of a woman in labor] and have to go to Fort Stockton and then we have somebody else down here having a heart attack and we don’t have an ambulance available?”

Rural obstetrics units require far more nurses than doctors to remain open, so diverting women elsewhere in the short term makes sense, said Dr. Tony Ogburn, who chairs the department of obstetrics and gynecology at the University of Texas Rio Grande Valley School of Medicine. “If you don’t have trained nurses there, it doesn’t matter if you have a physician that can do a C-section or do a delivery; you can’t take care of those patients safely,” he said.

Registered nurses who work in labor and delivery have completed specialized training, such as how to read a fetal heart monitor, so a nurse from the ER or another hospital unit can’t easily step in, Billings said. “It’s kind of like having a small football team or a small soccer team and not being able to pull from the bench,” he said.

Billings said he’s reached out to Dr. Michael Galloway, who chairs the department of obstetrics and gynecology at Texas Tech University Health Sciences Center in Odessa and has been helping coordinate efforts to recruit nurses from that city. But even if Odessa nurses agree to pick up some shifts at Big Bend Regional, they are likely a stopgap solution, said Billings, who questions how long they’d be willing to work so far away from home.

Luecke believes Big Bend Regional administrators are doing everything they can to improve nurse staffing. But, like Billings, he’s worried that these July temporary closures could become longer-term.

“We are hoping August will be a different situation,” Luecke said. “But it’s pretty iffy right now.”

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That is, until October, when patients with coronavirus infections began to reappear on the unit and, with them, the fear of many more to come. “It’s paralyzing, I’m not going to lie,” said Nester, who’s worked at the Worcester hospital for nearly two decades. “My little clan of nurses that I work with, we panicked when it started to uptick here.”

Adding to that stress is that nurses are caught betwixt caring for the bedside needs of their patients and implementing policies set by others, such as physician-ordered treatment plans and strict hospital rules to ward off the coronavirus. The push-pull of those forces, amid a fight against a deadly disease, is straining this vital backbone of health providers nationwide, and that could accumulate to unstainable levels if the virus’s surge is not contained this winter, advocates and researchers warn.

Nurses spend the most sustained time with a patient of any clinician, and these days patients are often incredibly fearful and isolated, said Cynda Rushton, a registered nurse and bioethicist at Johns Hopkins University in Baltimore.

“They have become, in some ways, a kind of emotional surrogate for family members who can’t be there, to support and advise and offer a human touch,” Rushton said. “They have witnessed incredible amounts of suffering and death. That, I think, also weighs really heavily on nurses.”

A study found that 64% of clinicians working as nurses, nurse practitioners or physician assistants at a New York City hospital screened positively for acute distress, 53% for depressive symptoms and 40% for anxiety — all higher rates than found among physicians screened.

Researchers are concerned that nurses working in a rapidly changing crisis like the pandemic — with problems ranging from staff shortages that curtail their time with patients to enforcing visitation policies that upset families — can develop a psychological response called “moral injury.” That injury occurs, they say, when nurses feel stymied by their inability to provide the level of care they believe patients require.

Dr. Wendy Dean, co-founder of , a nonprofit organization based in Carlisle, Pennsylvania, said, “Probably the biggest driver of burnout is unrecognized unattended moral injury.”

In parts of the country over the summer, nurses got some mental health respite when cases declined, Dean said.

“Not enough to really process it all,” she said. “I think that’s a process that will take several years. And it’s probably going to be extended because the pandemic itself is extended.”

Sense of Powerlessness

Before the pandemic hit her Massachusetts hospital “like a forest fire” in March, Nester had rarely seen a patient die, other than someone in the final days of a disease like cancer.

Suddenly she was involved with frequent transfers of patients to the intensive care unit when they couldn’t breathe. She recounts stories, imprinted on her memory: The woman in her 80s who didn’t even seem ill on the day she was hospitalized, who Nester helped transport to the morgue less than a week later. The husband and wife who were sick in the intensive care unit, while the adult daughter fought the virus on Nester’s unit.

“Then both parents died, and the daughter died,” Nester said. “There’s not really words for it.”

During these gut-wrenching shifts, nurses can sometimes become separated from their emotional support system — one another, said Rushton, who has about preventing moral injury among health care providers. To better handle the influx, some nurses who typically work in noncritical care areas have been moved to care for seriously ill patients. That forces them to not only adjust to a new type of nursing, but also disrupts an often-well-honed working rhythm and camaraderie with their regular nursing co-workers, she said.

At St. Vincent Hospital, the nurses on Nester’s unit were told one March day that the primarily postsurgical unit was being converted to a COVID unit. Nester tried to squelch fears for her own safety while comforting her COVID-19 patients, who were often elderly, terrified and sometimes hard of hearing, making it difficult to communicate through layers of masks.

“You’re trying to yell through all of these barriers and try to show them with your eyes that you’re here and you’re not going to leave them and will take care of them,” she said. “But yet you’re panicking inside completely that you’re going to get this disease and you’re going to be the one in the bed or a family member that you love, take it home to them.”

When asked if hospital leaders had seen signs of strain among the nursing staff or were concerned about their resilience headed into the winter months, a St. Vincent spokesperson wrote in a brief statement that during the pandemic “we have prioritized the safety and well-being of our staff, and we remain focused on that.”

Nationally, the viral risk to clinicians has been well documented. From March 1 through May 31, were health care workers, one-third of them in nursing-related occupations, according to data published last month by the Centers for Disease Control and Prevention.

As cases mount in the winter months, moral injury researcher Dean said, “nurses are going to do the calculation and say, ‘This risk isn’t worth it.’”

Juliano Innocenti, a traveling nurse working in the San Francisco area, decided to take off for a few months and will focus on wrapping up his nurse practitioner degree instead. Since April, he’s been seeing a therapist “to navigate my powerlessness in all of this.”

Innocenti, 41, has not been on the front lines in a hospital battling COVID-19, but he still feels the stress because he has been treating the public at an outpatient dialysis clinic and a psychiatric hospital and seen administrative problems generated by the crisis. He pointed to issues such as inadequate personal protective equipment.

Innocenti said he was concerned about “the lack of planning and just blatant disregard for the basic safety of patients and staff.” Profit motives too often drive decisions, he suggested. “That’s what I’m taking a break from.”

Building Resiliency

As cases surge again, hospital leaders need to think bigger than employee assistance programs to backstop their already depleted ranks of nurses, Dean said. Along with plenty of protective equipment, that includes helping them with everything from groceries to transportation, she said. Overstaff a bit, she suggested, so nurses can take a day off when they hit an emotional cliff.

The American Nurses Association, the American Association of Critical-Care Nurses (AACN) and several other nursing groups have with links to mental health programs as well as tips for getting through each pandemic workday.

Kiersten Henry, an AACN board member and nurse practitioner in the intensive care unit at MedStar Montgomery Medical Center in Olney, Maryland, said that the nurses and other clinicians there have started to gather for a quick huddle at the end of difficult shifts. Along with talking about what happened, they share several good things that also occurred that day.

“It doesn’t mean that you’re not taking it home with you,” Henry said, “but you’re actually verbally processing it to your peers.”

When cases reached their highest point of the spring in Massachusetts, Nester said there were some days she didn’t want to return.

“But you know that your friends are there,” she said. “And the only ones that really truly understand what’s going on are your co-workers. How can you leave them?”

This <a target="_blank" href="/public-health/for-nurses-feeling-the-strain-of-the-pandemic-virus-resurgence-is-paralyzing/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">