Without much fanfare — or time for opponents to respond — they abandoned the state’s relatively loose rules for getting an exemption and issued a regulation requiring families to consult personally with local public health departments before obtaining an immunization waiver.

The new rule sidestepped potential ideological firefights in the state Legislature, which have plagued lawmakers in other states trying to crack down on vaccination waivers. The regulation had a dramatic effect. In the first year, the Michigan Department of Health and Human Services reported that the number of statewide waivers issued had plunged 35 percent. Today, Michigan is in the middle of the pack among vaccination rates.

“The idea was to make the process more burdensome,” said Michigan State University health policy specialist Mark Largent, who has written extensively about vaccines. “Research has shown that if you make it more inconvenient to apply for a waiver, fewer people get them.”

Michigan’s experience demonstrates a way for governments to increase immunization rates without having to address religious or philosophical opposition to vaccines.

For many years, opposition to mandatory childhood vaccines has served as a frequent rallying point for those who see immunizations as interference with nature’s intentions, rebel against them as government meddling in family affairs or raise concerns about their safety.

Vaccine advocates and health professionals regard these views as dangerous, noting that the drugs have dramatically lowered the number of serious childhood illnesses and that studies suggesting they are not safe have been debunked. They also note that vaccines’ proven effectiveness lies in “herd immunity”— the higher the participation rate, the greater the community’s protection against outbreaks of infectious disease.

Many states adopt strategies to curb exemptions “by making applications complicated to fill out or complete,” according to University of Georgia public policy expert W. David Bradford, who studies immunization. Some states require parents to notarize applications or have them certified by a physician before sending them in, and “generally speaking, anything that raises the opportunity cost [of exemptions] works to some degree,” Bradford said. “Michigan took it a step further.”

Increasing the number of vaccinated kids in Michigan, which has a Republican governor and Republican majorities in both legislative houses, took a degree of political finesse.

“Health and Human Services wanted to do something, but the legislative option wasn’t there,” Largent said. Instead, Michigan decided to use a strategy he calls “inconvenience.”

Since 1978, Michigan had required schoolchildren entering kindergarten and middle school to obtain vaccination waiver certificates from county officials. “Some counties allowed you to do it over the phone; in others you mailed in a form and some even let you do it online,” Largent said. But in studying vaccine policy across the country, he noted, “one thing is really clear — health departments that have much lower rates.”

Michigan offered the perfect vehicle for introducing inconvenience into the process. The Joint Committee on Administrative Rules reviews state agency regulations and, if it takes no action, allows them to go into effect after 15 legislative days. The committee is composed of lawmakers, giving it a legislative imprimatur, but it is not the Legislature itself, thus avoiding the political rancor that can accompany debate on controversial issues.

During the 2013-14 school year, the federal Centers for Disease Control and Prevention found, Michigan had of children entering kindergarten who had been exempted from vaccinations.ÌýThe state Health and Human Services officials proposed a simple requirement: Parents seeking vaccine waivers must be briefed in person by a county health educator before a waiver would be granted. The joint committee approved the rule Dec. 11, 2014. It tookÌýeffect Jan. 1, 2015.Ìý

“We were not aware of the rule until the day it happened,” said Suzanne Waltman, president of Michigan for Vaccine Choice, an anti-vaccine organization. “We thought it was a stealth move.”

The office of Gov. Rick Snyder did not respond directly to requests for comment on the political hazards of vaccine policy. Retired Republican state Sen. John Pappageorge, co-chair of the administrative rules committee in 2014, voted to adopt the rule and described the procedure as a simple one designed to ensure “that implementation is in concurrence with the law.” Republican Rep. Tom McMillin, who was co-chair of the committee at the time and voted against the rule, did not respond to requests for an interview.

In a look at ,Ìýbefore 2015, about Ìýdid not get the fourth round of immunizations for diphtheria, tetanus and pertussis that is required by the state. That had fallen to ,Ìýslightly better than the national average.

The Traverse City outbreaks were overshadowed in the national media by a more dramatic measles outbreak in Southern California’s Disneyland, which also occurred over the 2014-15 holidays and ultimately led to 150 cases of the disease. But the states’ responses were quite different.

California’s solution was what Largent calls “eliminationism.” The state Legislature, with Democratic supermajorities, passed a measure doing away with religious and philosophical vaccine exemptions. Passage of the law triggered among opponents of vaccines.ÌýBesides California, only West Virginia and Mississippi .

Largent said a small number of children need waivers for medical reasons, usually because of allergies or immune deficiencies. Much larger numbers seek waivers for religious or philosophical reasons.

“The idea was to bring the waiver rate down,” Michigan Health and Human Services spokeswoman Angela Minicuci said. “From the perspective of the general population, vaccinations are recommended. This doesn’t take away choice. It simply ensures that people have education.”

But Largent said most vaccine opponents are not necessarily swayed by arguments in favor of immunization. Instead, “by heightening the burden, you change some of the incentives” for obtaining waivers. “Moral claims and ideology don’t matter as much when it’s inconvenient.”

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Three years later California thumbed its nose at the ban by starting its own multi-billion dollar stem cell program, and several states followed suit. Even though the restrictions were lifted in 2009, the insurgent movement survived and grew. Today at least seven states offer stem cell researchÌý funding or other incentives to local scientists and industry.

These initiatives have not yet produced the eagerly anticipated “cures” for conditions such as melanoma or Parkinson’s disease. But early public disappointment has yielded to the realization that years of research lie ahead before treatments can routinely enter the marketplace.

Still, as an engine for generating economic development and jobs, and as a mechanism for enhancing local scientific prestige, stem cell research for many states appears to be worth the investment.

“We want to show what we have,” said Dan Gincel, executive director of the Maryland Stem Cell Research Fund. He pointed to a sophisticated science community and easy access to the National Institutes of Health and the Food and Drug Administration.

The Maryland fund during the past eight years has used between $9 million and $12 million annually in state-appropriated funds to write grants to “incentivize the industry,” Gincel said. The money must be spent in Maryland, and grantees must be Maryland-based researchers, institutions or firms. “We’re still in the early stages of the technology—mostly basic research,” Gincel said.

And although the political and social tumult that retarded embryonic stem cell research early in the century still smolders, as the current debate over funding for Planned Parenthood can attest, the use of stem cells from adults has blunted much of the controversy.

“There was no extreme pushback,” said pediatrician Jakub Tolar, head of the University of Minnesota’s Stem Cell Institute and co-chairman of Regenerative Medicine Minnesota, a $50 million stem cell research program created last year by the state’s Republican-controlled legislature and signed into law by its Democratic governor. “My experience is that most parents or people with a particular condition could not care less about the politics.”

Ìýare unspecialized cells that develop and grow into the tissue- or organ-specific cells that make up the body of a living organism, everything from muscle and bone, to lungs and brain. Stem cells have many uses, but public attention for several years has focused on “cell-based therapies,” also known as “regenerative medicine,” in which stem cells are induced to form a particular type of adult cell to rebuild damaged or diseased parts of the body: a heart wall scarred by heart attacks; an injured spinal cord; burn damage; the effects of diabetes or Parkinson’s disease.

Controversy arose early in the century over the use of embryonic stem cells, which can differentiate into any cells in the body, but which are obtained by destroying unneeded human embryos created through in vitro fertilization. Anti-abortion groups and religious conservatives opposed embryonic stem cell research, and Bush in 2001 created after his order because of concerns over the sanctity of life.

Three years later California voters approved ballot Proposition 71, creating the (CIRM)Ìýto make grants and loans for stem cell research, funding it with a $3 billion bond issue—which is generating a total of $6 billion with interest and is expected to last until 2020.

“Without George Bush, this agency would not exist,” said David Jensen, publisher of California Stem Cell Report, a blog focused on the California institute. “The campaign raised expectations that therapies were right around the corner. The federal government wasn’t funding it, and the voters said that since we want to save lives, we’ll fund it.”

The institute in the past decade has become one of the most important and perhaps the biggest nonfederal dedicated stem cell research center in the world, spending about $180 million per year. Different parts of the National Institutes of Health spent a combined $1.4 billion on stem cell research in 2014.

Over the years the California institute has endured sharp criticism for failing to deliver cures and spending around 90 percent of its funds on basic research while ignoring drug development.

An Institute of Medicine study in 2012 also warned of cronyism, noting that the vast majority of CIRM grants were going to academic institutions whose members sat on the board of directors. Early critics also questioned whether usurping a federal research agenda was the best use of California’s tax dollars.

Much of this was dictated by Proposition 71 itself. The law mandates who sits on the board. It also provides the money, and the institute must spend it. In a California-centric program, supporters say, conflicts of interest are endemic, and board members frequently recuse themselves during the grant process.

C. Randal Mills, chosen in 2014 as the institute’s new president and chief executive officer, said the organization is adjusting to “a world that has changed significantly” since 2004 by moving away from simply funding good ideas in isolation to what he describes as a “system-based agency.”

Last year the institute had 10 programs in clinical trials, but expects to have 20 by the end of this year.

“We’re setting up continuous paths to move basic research to clinical trials,” he added. “It’s like a train moving down a track, where each grant is the link to the next step down the line.” Ìý

In 2009, President Barack Obama on embryonic stem cell research,Ìýbut by that time researchers were already using adult stem cells extensively and had learned to cells into embryonic-like induced pluripotent stem cells.

Despite the improved national climate, states, both for economic and scientific reasons, have continued to fund their own programs. NIH lists initiatives in six states, not counting Minnesota, and other reports have suggested that as many as 15 states either have dedicated programs or fund stem cell research or did so in the past.

Yet in a discipline that is just beginning to enter a translational phase, it is hard to evaluate the effectiveness of individual programs: “It’s a huge field, and it’s still early,” said Heather Rooke, scientific director for the International Society for Stem Cell Research. “States will continue to do basic research, and California has certainly already had important influence driving the research to the clinic.”

Results will take time, agreed Minnesota’s Tolar, but it is worth the trouble: “We started on drugs a hundred years ago. Then we went to monoclonal antibodies—biologicals,” he said. “We are now getting ready to use cells as a third way of doing medicine. We are at a historical sweet spot.”

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The (PCORI)Ìýalready has funded 468 studies, and last month opened the second phase of a program to create research networks covering specific diseases and involving millions of patients across the country.

The institute’s work, known as “comparative effectiveness research,” poses deceptively simple questions to find out vital information about which therapy or medication works best in the real world. Institute research goes beyond clinical trials and so-called “best practices” and extracts evidence from the individual experiences of massive numbers of patients.

Early results are encouraging. For example, many older patients fear the side effects of blood thinners, even though they decrease the incidence of stroke by 50 percent, but an of 12,500 stroke patients with atrial fibrillation found that the use of the blood thinning drug warfarin worked just as well without causing undue bleeding for patients over 80 as it did for younger patients. Another Ìýof children suffering from osteomyelitis, a bacterial bone inflammation, found that kids could take antibiotics orally instead of through an IV, a complicated and unpleasant procedure with risk of infection. The study reached that assessment after reviewing data from more than 2,000 children and adolescents treated at 36 children’s hospitals that have various protocols for handling the disease.

“We like studies embedded in real world settings, with big samples,” said Joe Selby, the institute’s executive director who is also a family practitioner, “in part because you want to be sure of the answer.”

Yet, some experts caution that it is too soon to proclaim the institute a success: “The jury is still out,” said Emory University Health economist Victoria Phillips. “We’ll need to look at what they deliver. Does the focus on patients disseminate the evidence more quickly and lead to faster implementation?” she asked. Other questions she raised: Is the integration between patients and researchers a success? Could another party do it more cheaply?

The institute, established in 2011as part of the Affordable Care Act, ,Ìýwith Republican opponents charging that it would be used to ration health care or even to serve as a “death panel” to determine who gets treatment and who does not.Ìý But the work has gone forward and raised few, if any, complaints.

The institute is a nonprofit financed from a trust fund set up by the Affordable Care Act that is expected to provide around $3 billion that must be spent by the end of 2020.

“Our job is to provide evidence,” Selby said. “We do not make policy or write guidelines. What patients and clinicians do with the evidence will be done by them, not us.”

In 2014 the institute launched the Patient-Centered Outcomes Research Networks, a program creating formal organizations overseen by medical professionals with patient participation and capable of conducting research surveys and studies into many diseases and conditions. These include both Clinical Data Research Networks, usually based at large university medical centers with access to repositories of millions of electronic health records, and Patient-Powered Research Networks that link thousands of patient volunteers with academic partners. The institute funded the first phase of the program for $93.5 million. Phase Two began Oct. 1 and will cost $142.5 million for three years.

Instead of merely funding individual studies, the networks give the institute additional tools for researchers to conduct multiple studies with resources already in place. Clinical Data Networks could enable medical professionals to query the records of millions of patients to learn the results of past or current medical care. One set for this network is to determine the optimal daily dose of aspirin to help prevent heart attack or stroke in people with coronary artery disease.

Patient Powered Research Networks partner academic researchers with patients, who help set the research agenda. The networks, working with patient-focused groups, recruit participants and identify concerns for potential studies.

In both types of networks, leaders vet research proposals, query their groups and send the resulting data to the research teams. The teams do not see patients’ individual medical records. Institute-funded studies must be peer-reviewed, and researchers must also prepare separate 500-word summaries of their results for clinicians and patients and post them on the institute’s website.

Each clinical network is required to research one common condition and one rare condition, but over time they are expected to be able to address practically any disease. So far, there are 13 clinical networks examining conditions that include breast cancer, anemia and atrial fibrillation, muscular dystrophy, cystic fibrosis and congenital heart defects.

“We’re trying to build a model that’s cheaper to use and more efficient” than conventional research trials, said Russell L. Rothman, a primary care physician and leader of the Mid-South Clinical Data Research Network, which is based at Vanderbilt University in Nashville but can draw on a sample base of 9 million patients in its region. The network’s early work has focused on coronary heart disease, especially on disparities in care, and sickle cell anemia.

Rothman said the network has spent its first 18 months making record systems compatible and appointing committees of physicians, patients and other health care providers to vet research requests. “We can use electronic health record data, to identify patients with a particular condition and follow them over time,” he added.

Health economist Rachael Fleurence, in charge of supervising the networks and developing reliable methodologies for them, said her program has worked at “getting everybody organized” but the networks have now begun to do research.

One of the more unusual new networks is focused on care for mental health problems, especially depression, in underserved communities in Los Angeles and New Orleans.

Called the ,Ìýthe initiative grew from a collaboration begun by University of California at Los Angeles psychiatrist Kenneth Wells and Loretta Jones, the founder of the Los Angeles-based community organization Healthy African-American Families.

“It was very difficult to get the community to talk about depression,” Jones said, but in 2003 she and Wells sponsored a conference where they asked community members what was needed. The conference helped spur efforts to improve mental health care opportunities in the community. The network they built, now one of the institute’s Phase 2 Patient Participatory networks, expanded its model to New Orleans after Hurricane Katrina, and today involves as many as 250,000 people in Louisiana and California.

The key feature of comparative effectiveness research, no matter how it is conducted, is to “improve patient care,” the Mid-South’s Rothman said. “Clinical trials typically test the effects of drugs against a placebo, while comparative effectiveness research compares one standard treatment to another in a real world situation to see what works better. We’re taking the next step.”

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For the high percentages of elderly and uninsured patients who live in rural areas, closures mean longer trips for treatment and uncertainty during times of crisis. “I came to the emergency room when I had panic attacks,” said George Taylor, 60, a retired federal government employee. “It was very soothing and the staff was great. I can’t imagine Mount Vernon without a hospital.”

The Kansas-based National Rural Health Association, which represents around 2,000 small hospitals throughout the country and other rural care providers, says that 48 rural hospitals have closed since 2010, the majority in Southern states, and 283 others are in trouble. In Texas along, 10 have changed.Ìý

“If there was one particular policy causing the trouble, it would be easy to understand,” said health economist Mark Holmes, from the University of North Carolina, whose rural health research program studies national trends in rural health care. “But there are a lot of things going on.”

Experts and practitioners cite declining federal reimbursements for hospitals under the Affordable Care Act as the principal reason for the recent closures. Besides cutting back on Medicare, the law reduced payments to hospitals for the uninsured, a decision based on the assumption that states would expand their Medicaid programs. However, almost two dozen states have refused to do so. In addition, other Medicare cuts caused by a budget disagreement in Congress have also hurt hospitals’ bottom lines.

But rural hospitals also suffer from multiple endemic disadvantages that drive down profit margins and make it virtually impossible to achieve economies of scale.

These include declining populations; disproportionate numbers of elderly and uninsured patients; the frequent need to pay doctors better than top dollar to get them to work in the hinterlands; the cost of expensive equipment that is necessary but frequently underused; the inability to provide lucrative specialty services and treatments; and an emphasis on emergency and urgent care, chronic money-losers.

‘Another Disaster’Ìý

Rural health care experts caution that national and state officials need to address the problems for rural hospitals or they could face a repeat of the catastrophic closings that followed changes in the Medicare payment system 30 years ago. That 1983 change, called the “prospective payment system,” established fixed reimbursements for care instead of payments based on a hospital’s reported costs. That change rewarded large, efficient providers, but 440 small hospitals closed before the system was adjusted in 1997 to help them. Those adjustments created the for some small, isolated facilities, which are exempted from the fixed payment system.

“And now, beginning in 2010, we’ve had another series of cuts that are all combining to create another expansion of closures just like we saw in the ‘90s,” said Brock Slabach, senior vice president of the Rural Health Association. “We don’t want to wake up with another disaster.”

The current surge in closures means federal officials need to come up with new legislation to halt the recent cuts to small hospitals in order to “buy time” to figure out how rural hospitals should effectively operate in the future, said the association’s chief lobbyist, Maggie Elehwany. “It is important to stop the bleeding right now.”

In Mount Vernon, a town of 2,678 people nestled in grassland and dairy country about two hours east of Dallas, family practitioner on the now-vacant hospital building to convert it into an outpatient and urgent care clinic at his own expense. Reopening may be a risky move, he acknowledged, but the need is there.

“The community went into panic mode,” he said. “I figured I had to step up.”

The non-profit ETMC Regional Healthcare System, based in Tyler, Texas, closed the Mount Vernon hospital and two others of its then-12 rural hospital affiliates because it could no longer sustain operating losses that had persisted for five years.

“There was no ill will,” Franklin County Judge Scott Lee said in an interview from his Mount Vernon office. “They were losing money. We had a good working relationship for years, and they had a business decision to make.”

Mount Vernon’s IssuesÌý

Perry Henderson, senior vice president of affiliate hospitals for ETMC, a major health care provider in East Texas, noted that rural hospitals have many uninsured patients, and Medicare accounts for “60 to 70 percent of the business,” while in “Dallas or Houston it’s a fraction of that.”

Mount Vernon, with lakefront properties that are attractive to retirees, has its share of elderly patients. Henderson also noted that many rural hospitals also have to deal with large numbers of agricultural accidents. Farming, another Mount Vernon staple, is one of the country’s most dangerous occupations. Finally, he added, country roads bring large numbers of traffic accidents. When there’s no hospital, emergencies mean longer trips to get help.

Henderson and other experts cite three reasons for the rash of closures nationally. Sequestration, the across-the-board federal budget cut that arose out of the legislative impasse between the Obama administration and congressional Republicans, has resulted in a 2 percent reduction in Medicare reimbursements since 2013.

“If Medicare is 50 percent of your revenue and you lose two points,” North Carolina’s Holmes said, “it can be a killer.”

Rural hospitals took a second hit from the federal health law’s reductions in “disproportionate share hospital” payments to hospitals with large numbers of indigent and uninsured patients. Federal officials made the cuts assuming that the law would assure that more patients had insurance.

It hasn’t worked well in rural areas, the Rural Health Association’s Elehwany said, because annual deductibles for the new insurance plans, which come out of consumers’ pockets, “are running between $2,500 and $5,000,” and people can’t pay them.

And in communities such as Mount Vernon, this problem is exacerbated because Texas, along with 22 other states, has refused to expand Medicaid, a key provision of the Affordable Care Act.

“That’s a big deal,” ETMC’s Henderson said. “That’s when we had the hurt.”

Latortue, who came to Mount Vernon as an ETMC hospital doctor in 2008, appears undaunted by the challenges of reinventing the hospital, which was treating an average of eight inpatients a week when it closed. Still, he said, “I’m very busy, and patients need to be seen—we’ll be all right.”

He intends to provide both outpatient services, including lab work, at the new clinic, and emergency care, stabilizing patients until they can be transferred to the Titus Regional Medical Center in Mt. Pleasant, 16 miles away, or to a smaller facility in Winfield, eight miles away. He also plans a wellness clinic to treat obesity and will offer Botox and laser cosmetic services. A cardiologist and a gastroenterologist will make weekly visits, and he is also looking for an ob-gyn.

Latortue got a favorable lease from the town of Mount Vernon and inherited an X-ray machine and other equipment from ETMC, but he still took out $150,000 in loans for remodeling and needs another $60,000 to $70,000 for equipment.

Still, none of this will replace the hospital, and his patients know it. “I live right behind the building,” said Mary Hunter, a very fit grandmother of 73. “I’ve had very good health until my blood pressure spiked last week,” she said. “We retired in 2006 and moved here, partly because of the hospital. And now it’s gone.”

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