Eleven states and Washington, D.C., together provide full health insurance coverage to more than 1 million low-income immigrants regardless of their legal status, according to state data compiled by Ñî¹óåú´«Ã½Ò•îl Health News. Most aren’t authorized to live in the U.S., state officials say.

Enrollment in these programs could nearly double by 2025 as at least seven states initiate or expand coverage. In January, Republican-controlled Utah will start covering children regardless of immigration status, while New York and California will widen eligibility to cover more adults.

“These are kids, and we have a heart,” said Utah state Rep. Jim Dunnigan, a Republican who initially opposed his state’s plan to cover children lacking legal status but relented after compromises including a cap on enrollment.

There are more than 10 million people living in the U.S. without authorization, according to estimates by the Pew Research Center. Immigrant advocates and academic experts point to two factors behind state leaders’ rising interest in providing health care to this population: The pandemic highlighted the importance of insurance coverage to control the spread of infectious diseases; and some states are focusing on people without legal status to further drive down the country’s record-low uninsured rate.

States have also expanded coverage in response to pleas from hospitals, lawmakers say, to reduce the financial burden of treating uninsured patients.

All states pay hospitals to provide emergency services to some unauthorized residents in emergency rooms, a program known as Emergency Medicaid. About a dozen states have extended coverage for only prenatal care for such people. Full state-provided health insurance coverage is much less common, but increasing.

An estimated living in the U.S. without authorization are uninsured, according to a KFF-Los Angeles Times survey. That’s more than five times the uninsured rate for U.S. citizens. Immigrants lacking authorization are ineligible for federal health programs. But states can use their own money to provide coverage through Medicaid, the state-federal insurance program for low-income people.

California was the first state to begin covering immigrants regardless of their legal status, starting with children in 2016.

“This is a real reflection of the conflict we have in the country and how states are realizing we cannot ignore immigrant communities simply because of their immigration status,” said Adriana Cadena, director of the advocacy group Protecting Immigrant Families. Many of the millions of people without permanent legal residency have been in the United States for decades and have no path to citizenship, she said.

These state extensions of health coverage come against a backdrop of rising hostility toward migrants among Republicans. The U.S. Border Patrol apprehended nearly 1.5 million people in fiscal year 2023 after they crossed the southern border, a record. GOP presidential candidates have portrayed the border as in crisis under Biden, and dangers of illegal immigration, like increasing crime, as the nation’s top domestic concern.

Simon Hankinson, a senior research fellow specializing in immigration issues with the conservative Heritage Foundation, said states would regret expanding coverage to immigrants lacking permanent legal residency because of the cost. Illinois, he noted, recently paused enrollment in its program over financial concerns.

“We need to share resources with people who contribute to society and not have people take benefits for those who have not contributed, as I don’t see how the math would work in the long run,” Hankinson said. “Otherwise, you create an incentive for people to come and get free stuff.”

Most adults lacking authorization work, of the U.S. labor force, according to the Pew Research Center. The state with the most unauthorized residents with state-provided health insurance is California, which currently covers about 655,000 immigrants without regard for their legal status. In January, it will expand coverage to people ages 26-49 regardless of their immigration status, benefiting an estimated 700,000 additional Californians.

Connecticut, Maine, Massachusetts, New York, Rhode Island, Vermont, Washington, D.C., and Washington state also provide full coverage to some people living in the U.S. without authorization. New York and Washington state are expanding eligibility next year.

Oregon, Colorado, and New Jersey in recent years began covering more than 100,000 people in total regardless of legal status. Minnesota will follow in 2025, covering an estimated 40,000 people.

While states are expanding coverage to people living in the U.S. potentially without authorization, some are imposing enrollment limits to control spending.

The cost of Utah’s program is capped at $4.5 million a year, limiting enrollment to about 2,000 children. Premiums will vary based on income but cost no more than $300 a year, with preventive services covered in full.

“The pandemic highlighted the need to have coverage for everybody,” said Ciriac Alvarez Valle, senior policy analyst for Voices for Utah Children, an advocacy group. “It will make a huge impact on the lives of these kids.”

Without coverage, many children use emergency rooms for primary care and have little ability to afford drugs, specialists, or hospital care, she said. “I am not sure if this will open the door to adults having coverage, but it is a good step forward,” Alvarez Valle said.

Colorado also limits enrollment for subsidized coverage in its program, capping it at 10,000 people in 2023 and 11,000 in 2024. The 2024 discounted slots were booked up within two days of enrollment beginning in November.

Adriana Miranda was able to secure coverage both years.

“You feel so much more at ease knowing that you’re not going to owe so much to the hospitals,” said Miranda, 46, who is enrolled in a private plan through OmniSalud, a program similar to the state’s Obamacare marketplace in which low-income Coloradans without legal residency can shop for plans with discounted premiums.

Miranda left Mexico in 1999 to follow her two brothers to the United States. She now works at Lamar Unidos, a nonprofit immigrant rights group.

Before she had health insurance, she struggled to pay for care for her diabetes and racked up thousands of dollars of debt following foot surgery, she said. Under the state program, she doesn’t pay a monthly premium due to her low income, with a $40 copay for specialist visits.

“I was really happy, right? Because I was able to get it. But I know a lot of people who also have a lot of need couldn’t get it,” she said.

OmniSalud covers only a small fraction of the more than 200,000 people living in Colorado without authorization, said Adam Fox, deputy director of the Colorado Consumer Health Initiative. But starting in 2025, all low-income children will be able to be covered by the state’s Medicaid or the related Children’s Health Insurance Program regardless of immigration status.

“There is a growing acknowledgement that people regardless of their immigration status are part of the community and should have access to health care in a regular, reliable manner,” Fox said. “If they don’t, it adds costs and trauma to the health systems and communities.”

Ñî¹óåú´«Ã½Ò•îl Health News senior audio producer Zach Dyer contributed to this report.

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Democratic Gov. Gavin Newsom to prohibit coroners, medical examiners, physicians, or physician assistants from listing excited delirium on a person’s death certificate or in an autopsy report. Law enforcement won’t be allowed to use the term to describe a person’s behavior in any incident report, and testimony that refers to excited delirium won’t be allowed in civil court. The law takes effect in January.

The term excited delirium has been around for decades but has been used increasingly over the past 15 years to explain how a person experiencing severe agitation can die suddenly through no fault of the police. It was cited as a legal defense in the 2020 deaths of George Floyd in Minneapolis; Daniel Prude in Rochester, New York; and Angelo Quinto in Antioch, California, among others.

“This is a watershed moment in California and nationwide,” said Joanna Naples-Mitchell, a lawyer with the New York-based , who co-authored a on the use of the diagnosis.

“In a wrongful death lawsuit, if excited delirium comes up, it’s a big hurdle for a family getting justice if their family member was actually killed by police,” Naples-Mitchell said. “So, now it will be basically impossible for them to offer testimony on excited delirium in California.”

Even though the new law makes California the first state to no longer recognize excited delirium as a medical diagnosis, several national medical associations already discredited it. Since 2020, the and the have rejected excited delirium as a medical condition, noting the term has disproportionately applied to Black men in law enforcement custody. This year, the National Association of Medical Examiners as a cause of death, and the American College of Emergency Physicians is expected to vote this month on whether to formally disavow its supporting excited delirium as a diagnosis. That white paper proposed individuals in a mental health crisis, often under the influence of drugs or alcohol, can exhibit superhuman strength as police try to control them, and then die from the condition.

In the case of Quinto, his mother, Cassandra Quinto-Collins, had called Antioch police two days before Christmas because her son was experiencing a mental health crisis. She had subdued him by the time they arrived, she said, but officers held her 30-year-old son to the ground until he passed out.

In a harrowing home video taken by Quinto-Collins, which was broadcast nationally after his death, she asked police what happened as her son lay on the floor unconscious, hands behind his back in handcuffs. He died three days later in the hospital.

The Contra Costa County coroner’s office, part of the sheriff’s department, blamed Quinto’s death on excited delirium. The Quinto family has filed a wrongful death lawsuit against the county and is seeking to change the cause of death on his death certificate.

Quinto-Collins also testified in favor of the bill, AB 360, introduced by state Assembly member Mike Gipson, a Democrat. It sailed through the legislature with bipartisan support. No organization formally opposed the measure, including the California Police Chiefs Association, whose executive director declined to comment this week.

“There’s a lot more work to be done, but it is a unique window into some of the corruption, some of the things that we’ve allowed to happen under our noses,” said Robert Collins, Quinto’s stepfather. “I think it’s really telling that California is ending it.”

Part of the problem with an excited delirium diagnosis is that delirium is a symptom of an underlying condition, medical professionals say. For example, delirium can be caused by old age, hospitalization, a major surgery, substance use, medication, or infections, said Sarah Slocum, a psychiatrist in Exeter, New Hampshire, who co-authored a published in 2022.

“You wouldn’t just put ‘fever’ on someone’s death certificate,” Slocum said. “So, it’s difficult to then just put ‘excited delirium’ on there as a cause of death when there is something that’s underlying and driving it.”

In California, some entities already had restricted the use of excited delirium, such as the , which prohibits the term in its written reports and policy manual.

But these changes confront decades of conditioning among law enforcement and emergency medical personnel who have been taught that excited delirium is real and trained how to handle someone suspected of having it.

“There needs to be a systematic retraining,” said Abdul Nasser Rad, managing director of research and data at , a nonprofit group that focuses on criminal justice reform and helped draft the California law. “There’s real worry about just how officers are being trained, how EMS is being trained on the issue.”

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, based in Huntington Beach, and , based in nearby Orange, both have plans aimed at Asian Americans, with extra benefits including coverage for Eastern medicines and treatments such as cupping and tui na massage. Alignment also has an offering targeting Latinos, while Long Beach-based has a product aimed at the LGBTQ+ community. All of them have launched since 2020.

While many Medicare Advantage providers target various communities with their advertising, this trio of companies appear to be among the first in the nation to create plans with provider networks and benefits designed for specific cultural cohorts. Medicare Advantage is typically cheaper than traditional Medicare but generally requires patients to use in-network providers.

“This fits me better,” said Clever Care member Tam Pham, 78, a Vietnamese American from Westminster, California. Speaking to Ñî¹óåú´«Ã½Ò•îl Health News via an interpreter, she said she appreciates the dental care and herbal supplement benefits included in her plan, and especially the access to a Vietnamese-speaking doctor.

“I can always get help when I call, without an interpreter,” she said.

Proponents of these new culturally targeted plans say they can offer not only trusted providers who understand their patients’ unique context and speak their language, but also special products and services designed for their needs. Asian Americans may want coverage for traditional Eastern treatments, while LGBTQ+ patients might be especially concerned with HIV prevention or management, for example.

Health policy researchers note that Medicare Advantage tends to be lucrative for insurers but can be a mixed bag for patients, who often have a limited choice of providers — and that targeted plans would not necessarily solve that problem. Some also worry that the approach could end up being a new vector for discrimination.

“It’s strange to think about commodifying and profiting off people’s racial and ethnic identities,” said Naomi Zewde, an assistant professor at the UCLA Fielding School of Public Health. “We should do so with care and proceed carefully, so as not to be exploitive.”

Still, there’s plenty of evidence that patients can benefit from care that is targeted to their race, ethnicity, or sexual orientation.

A November 2020 study of almost 118,000 patient surveys, published in JAMA Network Open, underscored the need for a connection between physician and patient, finding that patients with the same racial or ethnic background as their physicians to rate the latter highly. A 2022 survey of 11,500 people around the world by the pharmaceutical company Sanofi showed a legacy of distrust in health care systems among marginalized groups, such as ethnic minorities, LGBTQ+ people, and people with disabilities.

Clever Care, founded by Korean American health care executive Myong Lee, aimed from the start to create Medicare Advantage plans for underserved Asian communities, said Peter Winston, the senior vice president and general manager of community and provider development at the company. “When we started enrollments, we realized there is no one ‘Asian,’ but there is Korean, Chinese, Vietnamese, Filipino, and Japanese,” Winston added.

The company has separate customer service lines by language and gives members flexibility on how and where to spend their allowances for benefits like fitness programs.

Winston said the plan began with 500 members in January 2021 and is now up to 14,000 (still very small compared with mainstream plans). Herbal supplement benefit dollars vary by plan, but more than 200 products traditionally used by Asian clients are on offer, with coverage of up to several hundred dollars per quarter.

Sachin Jain, a physician and the CEO of SCAN Group, said its LGBTQ+ plan serves 600 members.

“This is a group of people who, for much of their lives, lived in the shadows,” Jain added. “There is an opportunity for us as a company to help affirm them, to provide them with a special set of benefits that address unmet needs.”

SCAN has run into bias issues itself, with some of its employees posting hate speech and one longtime provider refusing to participate in the plan, Jain recounted.

Alignment Health offers a plan targeting Asian Americans in six California counties, with benefits such as traditional wellness services, a grocery allowance for Asian stores, nonemergency medical transportation, and even pet care in the event a member has a hospital procedure or emergency and needs to be away from home.

Alignment also has an offering aimed at Latinos, dubbed el Único, in parts of Arizona, Nevada, Texas, Florida, and California. The California product, an HMO co-branded with Rite Aid, is available in six counties, while in Florida and Nevada, it’s a so-called special needs plan for Medicare beneficiaries who also qualify for Medicaid. All offer a Spanish-speaking provider network.

Todd Macaluso, the chief growth officer for Alignment, declined to share specific numbers but said California membership in Harmony — its plan tailored to Asian Americans — and el Único together has grown 80% year over year since 2021.

Alignment’s marketing efforts, which include visiting places where prospective members may shop or socialize, are about more than just signing up customers, Macaluso said.

“Being present there means we can see what works, what’s needed, and build it out. The Medicare-eligible population in Fresno looks very different from one in Ventura.”

“Just having materials in the same language is important, as is identifying the caller and routing them properly,” Macaluso added.

Blacks, Latinos, and Asians overall are significantly more likely than white beneficiaries to choose Medicare Advantage plans, according to conducted for Better Medicare Alliance, a nonprofit funded by health insurers. (Latino people can be of any race or combination of races.) But it’s not clear to what extent that will translate into the growth of targeted networks: Big insurers’ Medicare Advantage marketing efforts often target specific racial or ethnic cohorts, but the plans don’t usually include any special features for those groups.

Utibe Essien, an assistant professor of medicine at UCLA, noted the historical underserving of the Black community, and that the shortage of Black physicians could make it hard to build a targeted offering for that population. Similarly, many parts of the country don’t have a high enough concentration of specific groups to support a dedicated network.

Still, all three companies are optimistic about expansion among groups that haven’t always been treated well by the health care system. “If you treat them with respect, and bring care to them the way they expect it, they will come,” Winston said.

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The rule, part of addressing the STI epidemic, took effect Jan. 1 for people with state-regulated private insurance plans and will kick in sometime later for the millions of low-income Californians enrolled in the state’s Medicaid program.

By making it easier and cheaper for Californians to self-administer tests in the privacy of their homes, the provision could bring better disease monitoring to rural and underserved parts of the state, reduce the stigma patients experience when seeking care and give them more control over their health, say experts on infectious diseases.

“This is the first law of its kind, and I’d say it’s kind of cutting-edge,” said Stephanie Arnold Pang, senior director of policy and government relations for the National Coalition of STD Directors. “We want to bring down every single barrier for someone to get STI testing, and out-of-pocket cost is a huge factor.”

But being first has its downsides. Because the concept of insurance coverage for home STI tests is so new, the state’s Medicaid program, Medi-Cal, could not establish by Jan. 1 the billing codes it needs to start paying for tests. Federal regulators also haven’t approved the tests for home use, which could make labs reluctant to process them. And a predicts most in-network health care providers won’t start prescribing home tests for at least a year until they adjust their billing and other practices.

Nevertheless, the situation is urgent and requires action, said state Sen. Richard Pan (D-Sacramento), a pediatrician who wrote the law.

“We have children born in California with syphilis,” Pan said. “You’d think that went away in the Victorian era.”

Even before covid, sexually transmitted infections hit all-time highs in the and for six years in a row, according to 2019 data from the Centers for Disease Control and Prevention. Rates of congenital syphilis, which babies contract from their mothers, illustrate the severity of the STI epidemic: Cases were up 279% from 2015 to 2019 nationally and 232% in California. Of the of congenital syphilis in California in 2019, 37 were stillbirths.

The pandemic only worsened the problem because health departments were overwhelmed responding to the covid emergency, and stay-at-home orders kept people away from clinics.

In surveys of public health programs across the country since May 2020, the National Coalition of STD Directors found that most respondents — up to 78% in — have diverted some of their STI workforces to test and monitor covid. that accompanied the most recent survey found that some STIs were “completely unchecked” due to reductions in clinic hours, diversion of resources, shortages of testing kits and staff burnout.

Some at-home STI tests screen for a single disease but other kits can collect and send samples to check for a variety of infections. Depending on the test, patients collect a drop of blood with a lancet, or swab their mouth, vagina, anus or penis.

Some tests require patients to send samples to a lab for analysis, while some oral HIV tests give results at home in a few minutes.

Ivan Beas, a 25-year-old graduate student at UCLA, was getting tested frequently as part of a two-year research study. When clinics closed during the pandemic, researchers sent him a home kit.

The kit, which tests for HIV, hepatitis C, herpes, syphilis, chlamydia, gonorrhea and trichomoniasis, was packaged discreetly and came with easy instructions. It took Beas about 10 minutes to prick his finger, swab his mouth and send the samples to the lab.

Beas wanted to continue screening himself every few months after the study ended, he said, but the kit he used retails for $289, which is out of reach for him.

The last time he went to a clinic in person, “I spent two hours waiting to even be seen by a doctor because of how busy they are,” he said. Until Medi-Cal begins covering home tests, he said, he will have to find time to get tested for free at a Planned Parenthood clinic.

“If insurance were to cover it, I’d definitely do it more,” he said.

Under California’s , plans regulated by the state must cover home STI tests when ordered by a health care provider.  

Privately insured Californians can take advantage of the coverage immediately. How much they will owe out-of-pocket for the tests — if anything — depends on the type of plan they have, whether their provider is in-network, and if they fall into a category the federal government has designated for free screening.

Medi-Cal patients almost never face out-of-pocket expenses, but they will have to wait for coverage because the Department of Health Care Services, which administers Medi-Cal, is working with the American Medical Association and the federal government to create billing codes. The reimbursement rates for those codes will then need federal approval.

The state doesn’t know how long that process will take, according to department spokesperson Anthony Cava.

The rule does not apply to the millions of Californians whose job-based health insurance plans are regulated by the federal government.

Other states and organizations have experimented with at-home STI tests. The public health departments in and the send free kits to residents who request them, but neither jurisdiction requires insurance coverage for them. The National Coalition of STD Directors is sending free kits to people through health departments in Philadelphia; Iowa; Virginia; Indiana; Puerto Rico; and Navajo County, Arizona. The list of recipients is expected to grow this month.

Iwantthekit.org, a project of Johns Hopkins University, has been sending free kits to Maryland residents since 2004, and to Alaskans since 2011. The program is funded by grants and works with local health departments.

Charlotte Gaydos, co-founder of the project, said that requests for test kits during the pandemic nearly tripled — and that she would expand to every state if she could bill insurance the way the California law mandates.

The tests fall into a murky regulatory area. While they have been approved by the Food and Drug Administration, none have been cleared for use at home. Patients are supposed to collect their own samples within the walls of a health facility, and some labs may not analyze samples collected at home.

Public health officials cited other potential challenges: Patients may not have the same access to counseling, treatment or referrals to other services such as food banks that they would receive at clinics. And although patients are supposed to self-report the results of their tests to public health authorities, some people won’t follow through.

Vlad Carrillo, 31, experienced such trade-offs recently. Carrillo used to get tested at a San Francisco clinic, where they could get counseling and other services. But Carrillo lost their apartment during the pandemic and moved about seven hours away to Bishop, the only incorporated city in rural Inyo County.

“Being away from the city, it took me a whole year to find a way to get tested,” Carrillo said.

Carrillo eventually got the kit through the mail, avoiding the stigma of going to the clinic in Bishop, which is “more focused on straight stuff,” like preventing pregnancy. Without the test, Carrillo couldn’t get PrEP, a medication to prevent HIV.

“Going without it for so long was really hard on me,” Carrillo said.

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As they fanned out to educate farmworkers on how to protect themselves from covid-19, they quickly learned that rumors and disinformation often account for most of the news farmworkers in the area are getting about the disease. The need for boosters and the looming threat of the omicron variant have made covid communication extra challenging.

“Now, we’re debunking the myths with the boosters. It’s like a never-ending story,” said Gallegos, executive director of the , based in Coachella.

Gallegos and her team huddle in the mornings to discuss a strategy on how to diffuse misinformation before it spreads. “Once we start hearing rumors, we try to get ahead of them and create messaging to debunk it before they start penetrating the fields like they did when we first started vaccinating in January.”

In January, the word in the fields was that covid vaccination would make you sterile. Now, people hear from friends and social media that the vaccines can turn you into a monkey, change your gender or clone you.

Gallegos and Riverside County health workers managed earlier in the year to get vaccines into the arms of , where dates, citrus and grapes are the dominant crops. That has eased the sales job for some of her crew of TODEC employees and volunteers.

“People that got vaccinated, they feel like they’re still here, they’re still alive,” she said. “People see science now.”

But equity issues that were evident in the first round of vaccines are more evident now, including access to health care, language barriers and misinformation, Gallegos said. Some workers don’t understand why they need a follow-up shot. Others are newcomer migrants who haven’t been vaccinated against covid at all.

Community health organizations have struggled to provide booster shots for the Latino community — whose members account of covid cases in California. By September, about of eligible Latinos had received at least one shot, the same rate as whites. But of the 23.4 million people 65 and older who had by Dec. 13, only were Latinos (who make of that age group), according to the Centers for Disease Control and Prevention. Latinos of other ages were also .

“Latinos don’t know who to turn to for accurate information,” said , an assistant professor at Arizona State University who has been working on vaccine communication. “The government hasn’t been doing the best job, the big national TV channels haven’t been doing that good of a job, and community organizations are working at a hyper-local level.”

One basic problem: Credible vaccine information and the science that supports it is not readily available in Spanish or other languages, said , an assistant clinical professor in family medicine at UCLA Health. “People are afraid to contract the virus in health care settings. Many avoided seeking care even when they were sick for fear of being put on ventilators, afraid they would never make it out of the hospital.”

The county has partnered with TODEC to send health care providers out to the fields and hold open vaccination and booster clinics on Fridays. This answers immigrants’ fears of going to the doctor and their concerns that side effects from the shot will cause them to miss work.

“Fridays gives them the opportunity to actually recover,” said Gallegos.

Castellon-Lopez has been conducting webinars for patients and community members to dispel myths and explain the shifting reality of the covid epidemic. “What we’re learning about covid is changing every day and that makes it difficult,” she said. “I think people appreciate having access to doctors who look like them and speak the language.”

Disinformation on , and messaging apps like WhatsApp is fueling continued vaccine hesitancy among Latinos, according to conducted by Change Research and the Latino Anti-Disinformation Lab. It found that almost 4 in 10 respondents had seen information that made them think the covid vaccines were not safe or effective.

Latino educators are seeking to smother misleading propaganda with culturally relevant, easy-to-understand, accurate information.

Lopez, at Arizona State University, created the Covid Health Animation Project, which makes cartoons that address covid misinformation. But he thinks health communicators need to inject some bawdiness into their scripts to get people’s attention.

“The type of comedy, the type of messaging, the wording we use, it’s G-rated,” said Lopez. He an animation that drops a few cuss words here and there. “That’s the way this population talks. We need to use some of the language that they use to reach out to the community that’s not getting vaccinated.”

Language barriers remain a consistent issue, especially for Indigenous-language speakers, said Odilia Romero, executive director of (CIELO), a Los Angeles nonprofit.

Pablo Ek Oxte, a 52-year-old plumber in Yucatán, Mexico, rolled up his sleeve for a booster shot on a recent Saturday morning after hearing about the vaccine clinic in a public service announcement produced by CIELO in his native Mayan language. The group has posted a series of vaccination in various Indigenous languages on social media sites.

“I relied on the information from CIELO,” said Oxte, who has asthma and diabetes. Although he speaks some Spanish, “I appreciate the information in my language,” he said.

In Oxnard, California, Francisco Didier Ulloa and Bernardino Almazán host a show on Radio Indígena in Spanish and Mixteco, an Indigenous Mexican language.

“A lot of our Indigenous brothers don’t speak Spanish, so it was necessary to convey the information in a way that they would listen and understand,” said Ulloa.

The Los Angeles County Department of Public Health has increased its social media memes and is testing strategies to narrow the vaccination gap between white and Latino residents. The state partnered with to create a series of and animations promoting vaccination and booster information.

“We want people to see themselves and their families reflected in these images and maybe do a double take and think twice about their own family’s situation,” said Alcaraz. “Maybe it changes their mind about the vaccine.”

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Diagnosed with asthma early in childhood, the ninth grader has come to detest the pistachio trees that surround her home because the dust, pesticides and other allergens that blow off the orchards often trigger an asthma attack — even infiltrating her home so that simple chores like vacuuming can be dangerous.

“We live so close to the fields — I breathe the dust and chemicals in,” said Ruby, 14, describing coughing and wheezing fits calmed by puffs from her emergency inhaler or breathing treatments from a nebulizer. “It gets so bad that my back hurts, my head hurts, my lungs hurt. I get sick and it gets really hard to breathe.”

Ruby is among roughly 2 million low-income Californians who have health insurance coverage from Medi-Cal, the state’s Medicaid program, and have been diagnosed with asthma, a chronic and expensive disease that costs California s in health care spending, missed work for parents and lost school days for kids.

The disease — exacerbated by air pollution and indoor threats like harsh cleaning products, cockroach infestations, dust and mold — hits low-income communities the hardest. Medi-Cal patients accounted for half the state’s asthma-related emergency and urgent care visits in 2016, even though they represented about one-third of the population, according to by state health officials.

Starting in January, California will embark on an ambitious experiment to control asthma in its most vulnerable patients. Medi-Cal will offer recipients like Ruby unconventional in-home “treatments” not traditionally considered health care: removing mold, installing air purifiers and even replacing carpeting, blinds and mattresses.

These are just a small part of Gov. Gavin Newsom’s sweeping $6 billion initiative to transform the largest Medicaid program in the country. The initiative, , will target the state’s sickest and most expensive patients and cover an array of new social services, including home-delivered healthy meals; help with grocery shopping, laundry and money management; and security deposits for homeless people in search of housing.

Newsom’s goal is to lower soaring Medi-Cal spending — which hit an astronomical $124 billion this fiscal year — by preventing costly care such as emergency room visits. But state health officials acknowledge the new asthma benefits may not actually save taxpayer money.

Nor will the benefits be distributed equally: Because Medi-Cal managed-care insurance plans have immense power to decide which new services to offer and to whom, the initiative will create a patchwork of haves and have-nots. Of the 25 participating insurance companies, in-home asthma services starting in January in 36 of the state’s 58 counties. Within those counties, some Medi-Cal recipients will qualify; others will not.

With just two weeks to go before the program debuts, many insurers are scrambling to establish networks of nonprofit organizations and private contractors that specialize in delivering in-home asthma services and home repairs.

In San Bernardino and Riverside counties, for example, about 400 patients served by the Inland Empire Health Plan — out of nearly 1.4 million Medi-Cal plan members — will have access to asthma services in the first year, largely because the insurer has identified only one organization equipped to handle the responsibility.

“If we don’t do this right, this dream can become a nightmare,” said Alexander Fajardo, executive director of El Sol Neighborhood Educational Center in San Bernardino, which is negotiating a contract with the insurer.

Fajardo said El Sol is frantically preparing. While his organization has experience providing asthma education, it doesn’t have expertise in medical billing, patient privacy regulations and managed-care contracts.

“This is new, so we still have to learn,” Fajardo said.

Jeanna Kendrick, the Inland Empire Health Plan’s senior director of care integration, called the experiment to develop new social services “probably the hardest thing we’ve ever done.” It pushes plans into uncharted territory, she said, contracting with community organizations and teaching them how to handle medical billing, for example.

“We really do need to be creative and have some wiggle room because this is brand-new for all of us,” Kendrick said.

Jacey Cooper, California’s Medicaid director, argued earlier this year that health plans will start small but add capacity over the five years of the initiative. The state is offering incentive payments to help plans launch new services and has set aside $300 million for the first half of 2022 alone.

The Department of Health Care Services, which administers Medi-Cal, could not say how many low-income Californians will receive new in-home asthma services, because they are voluntary, and as a result could not predict future costs. But Anthony Cava, a department spokesperson, showing that more than 220,000 Medi-Cal recipients have poorly controlled asthma. The state pays $200 to $350 for a typical asthma-related emergency room visit, and $2,000 to $4,000 a day for a typical inpatient hospitalization, department officials said.

Agency officials couldn’t confirm the asthma benefits will save money, saying the costs will be equal to or less than the costs of traditional medical treatments.

Under the program, health insurers will send contractors into houses and apartments to assess hazards and educate patients about conditions that can trigger asthma attacks. Insurance executives say they will consider approving any service that could help asthma patients — from replacing tattered carpets to buying nontoxic cleaning products and pillow dust covers — within the for each Medi-Cal recipient. The services will be available to both renters and homeowners.

“It’s not that somebody can just say they just want a brand-new $3,000 mattress,” said Dr. Takashi Wada, chief medical officer for the Inland Empire Health Plan. “But we do think a lot of these asthma attacks are preventable, and by avoiding illness, you’re also avoiding unnecessary hospital and emergency department visits.”

Fresno and Madera counties have some of the in the state. They also have the highest rates of childhood asthma-related ER visits in California, along with Imperial County on the Mexican border, according to .

Ruby and her family, who live in Madera, California, appear to be ideal candidates for state-funded asthma benefits, said Joel Ervice, associate director of Regional Asthma Management and Prevention, which lobbied for the new services. Both Ruby and her sister Yesenia, 20, have asthma and were frequent visitors to the ER during childhood.

But as in the Inland Empire, only a small share of Central Valley asthma patients will receive the new services initially. Ruby and her family hope they will be among the lucky ones but realize they may still have to rely on conventional treatments such as emergency inhalers — and the hospital if necessary.

“I’m taking my medication a lot right now — it would be good if my asthma got better,” said Ruby, who wants to be able to play outside her home and excel in outdoor school activities. “I’m having a hard time running the mile in school, so being able to run would be so great for me and my health.”

CalViva Health, a major insurer serving patients in the Central Valley, including the Marentes-Cabrera family, so far has identified one nonprofit organization to deliver services and is negotiating with others.

That organization, the Central California Asthma Collaborative, expects to be able to serve up to 500 people across seven counties next year. Unlike other nonprofit groups that are still assessing how to deliver services, the collaborative has already identified private contractors to remove mold, install bathroom or kitchen ventilation, and provide other services, co-director Kevin Hamilton said.

CalViva Health CEO Jeffrey Nkansah said asthma is one of the leading causes of hospitalization among the insurer’s enrollees.

“But right now, these conversations around identifying partners to deliver these asthma remediation services are fluid,” Nkansah said. “We’re still working hard to make sure we can get those services in place for Jan. 1.”

For the Marentes-Cabreras, the relentless clouds of dust and other toxins from orchards, combined with seasonal wildfire smoke, are the biggest problem. The particles infiltrate their lungs and their home, covering surfaces and caking the carpet, which they would like to replace. But they don’t have the money.

For now, Sandra Cabrera uses nontoxic cleaning products and daughters Ruby and Yesenia track their lung capacity with oxygen meters.

“I am trying to control what’s in the house to prevent them from getting sick, cleaning a lot and using different cleaners,” Cabrera said in Spanish. “We could use help to do more, but it’s really difficult.”

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Diaz, known as “Rock,” has been a tattoo artist for 26 years but still gets a little nervous when doing memorial tattoos, and this one was particularly sensitive. Diaz was inking a portrait of Philip Martin Martinez, a fellow tattoo artist and friend who was 45 when he died of covid-19 in August.

“I need to concentrate,” said Diaz, 52. “It’s a picture of my friend, my mentor.”

Martinez, known to his friends and clients as “Sparky,” was a tattoo artist of some renown in nearby Wilmington, in Los Angeles’ South Bay region. A tattoo had brought Sparky and Anita together; Sparky gave Anita her first tattoo — a portrait of her father — in 2012, and the experience sparked a romance. Over the years of their relationship, he had covered her body with intertwining roses and a portrait of her mother.

Now his widow, she was getting the same photograph that was etched on Sparky’s tomb inked into her arm. And this would be her first tattoo that Sparky had not applied.

“It feels a little odd, but Rock has been really good to us,” Anita Martinez said. Rock and Sparky “grew up together.” They met in the 1990s, at a time when there were no Mexican-American-owned tattoo shops in their neighborhood but Sparky was gaining a reputation. “It was artists like Phil that would inspire a lot of us to take that step into the professional tattoo industry,” Rock said.

After Sparky got sick, Anita wasn’t allowed in her husband’s hospital room, an isolating experience shared by hundreds of thousands of Americans who lost a loved one to covid. They let her in only at the very end.

“I got cheated out of being with him in his last moments,” said Martinez, 43. “When I got there, I felt he was already gone. We never got to say goodbye. We never got to hug.”

“I don’t even know if I’m ever going to heal,” she said, as Diaz began sketching the outlines of the portrait below her elbow, “but at least I’ll get to see him every day.”

According to a Harris Poll, almost 30% of Americans have at least one tattoo, a 10% increase from 2011. At least 80% of tattoos are for commemoration, said , a professor of sociology at York University in Toronto who has been researching memorial tattoos since 2009.

“Memorial tattoos help us speak our grief, bandage our wounds and open dialogue about death,” she said. “They help us integrate loss into our lives to help us heal.”

Covid, sadly, has provided many opportunities for such memorials.

Juan Rodriguez, a tattoo artist who goes by “Monch,” has been seeing twice as many clients as before the pandemic and is booked months in advance at his parlor in Pacoima, an L.A. neighborhood in the San Fernando Valley. Memorial tattoos, which can include names, portraits and special artwork, are common in his line of work, but there’s been an increase in requests due to the pandemic. “One client called me on the way to his brother’s funeral,” Rodriguez said.

Rodriguez thinks memorial tattoos help people process traumatic experiences. As he moves his needle over the arms, legs and backs of his clients, and they share stories of their loved ones, he feels he is part artist, part therapist.

Healthy grievers do not resolve grief by detaching from the deceased but by creating a new relationship with them, said, a therapist in Pasadena, California, who specializes in traumatic grief. “Tattoos can be a way of sustaining that relationship,” she said.

It’s common for her patients in the 20-to-50 age range to get memorial tattoos, she said. “It’s a powerful way of acknowledging life, death and legacy.”

Sazalea Martinez, a kinesiology student at Antelope Valley College in Palmdale, California, came to Rodriguez in September to memorialize her grandparents. Her grandfather died of covid in February, her grandmother in April. She chose to have Rodriguez tattoo an image of azaleas with “I love you” written in her grandmother’s handwriting.

The azaleas, which are part of her name, represent her grandfather, she said. Sazalea decided not to get a portrait of her grandmother because the latter didn’t approve of tattoos. “The ‘I love you’ is something simple and it’s comforting to me,” she said. “It’s going to let me heal and I know she would have understood that.”

Sazalea teared up as the needle moved across her forearm, tracing her grandmother’s handwriting. “It’s still super fresh,” she said. “They basically raised me. They impacted who I am as a person, so to have them with me will be comforting.”

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It can be extremely confusing, no matter how clever you are, to determine which bills you need to pay. If you’re sick, or have technological, cultural or language barriers — not to mention financial difficulties — navigating this maze can be especially intimidating.

A California law signed by Gov. Gavin Newsom last month may help you sort through a tangle of medical bills to figure out what your health plan will cover and when the coverage kicks in.

The law, , requires most state-regulated private-sector health plans to send enrollees updates, for every month in which they received care, showing how much they have paid toward their annual deductible — the amount a person must shell out before insurance begins to cover most of their care — and how close they are to reaching out-of-pocket limits, the amount after which the insurer pays for 100% of care.

The law, which takes effect in July, should help people with costly chronic conditions who need to keep better track of how much they owe, and healthy ones who rarely seek care but might suddenly encounter unexpected medical circumstances.

“It’s not that hard to hit those maximums, and it doesn’t take a cancer diagnosis to get there,” says Dylan Roby, a professor of public health at the University of California-Irvine. “It could be one ER visit with a procedure. A broken leg could get you there pretty easily.”

The new law requires health plans to send out-of-pocket updates via mail unless the insured opts for electronic delivery. The information must also be stored in a format that is accessible to customers at any time.

SB 368 “is part of a larger need to provide transparency about individuals’ out-of-pocket risks,” says Roby.

Consumers often are unaware, he notes, of what’s available for free under the Affordable Care Act, including preventive services like screening tests and immunizations. Most health plans offered through Covered California, the state’s ACA marketplace, also must cover outpatient services, including imaging, specialist appointments and physical therapy, before the deductible is met.

One potential pitfall of the new law, Roby observes, is that insurers can crunch numbers based only on the claims they’ve processed, and some doctors and other providers might take six months or more to file claims. That means the information plans send to enrollees could be outdated.

At present, state law imposes no specific requirement on insurers to inform enrollees of their current financial liabilities, but some plans already do so — either in the “explanation of benefits” they send after care is received, or in response to a customer request.

“This law makes an optional practice a requirement,” says state Sen. Monique Limón (D-Santa Barbara), who authored the legislation. “And it’s a good practice.”

The new law should be helpful to a growing number of people, given the of health plans with ever-larger deductibles.

Between 2012 and 2020, the percentage of California workers with single coverage who had an annual deductible of $1,000 or greater . And among families enrolled in health plans with deductibles, 70% had deductibles of $2,000 or higher last year, compared with 31% eight years earlier.

For the cheapest , the deductible this year is $6,300 for an individual and $12,600 for a family. And there’s a separate deductible for prescription drugs (the new law requires health plans to inform enrollees where they stand on all their deductibles).

As deductibles rise, health plan members are seeing the financial protection of their insurance kick in . And in many cases, after meeting their deductibles they still need to spend a thousand or more before reaching out-of-pocket spending limits for the year.

People with serious diagnoses such as cancer, HIV, multiple sclerosis or cystic fibrosis frequently make such calculations.

Stacey Armato, a 41-year-old mother of three in Hermosa Beach, California, has a 6-year-old son with cystic fibrosis, a serious progressive lung disease. Her son, Massimo, takes about a dozen medications, with costs well into the thousands of dollars each month.

Armato and her family are luckier than many: They have good insurance that limits their total spending on Massimo’s care to about $6,000 a year. But that is still enough to make them rethink spending plans at times. “I’m always going to prioritize my son’s care,” Armato says.

She likes the new law. “I think transparency about how much a patient is spending and what their financial obligations are is really important,” she says.

Some families coping with cystic fibrosis and other expensive illnesses face much starker trade-offs — choosing between treatment and paying their rent, for example. In those cases, it can be indispensable to know when the financial hemorrhaging will stop, easing pressure on the family budget.

The new law can also be useful if you, like many people, postponed an elective surgery because of the pandemic — a hip replacement or cataract removal, for example — and want to reschedule it now. The best timing, financially speaking, will be when you are close to reaching your deductible and out-of-pocket spending limit — or if you already have reached them. If you know where you stand, you can schedule the procedure for a time when your financial liability will be minimal.

The law might also help people avoid paying money they don’t actually owe. “Sometimes when people see any kind of bill, they think they need to pay it,” says Jen Flory, a policy advocate at the Western Center on Law & Poverty, which supported the legislation. “So unless they understand that, ‘Oh, I reached my deductible, or my out-of-pocket max,’ people panic and do whatever they need to do to pay the bill. And it can be hard to get the money back from providers if they pay unnecessarily.”

Although your insurer is not required to provide your out-of-pocket status until the law takes effect in July, you can still call the customer help line and ask for it — or for clarification about a bill. If you don’t get the answer you want, ask your health plan to tell you who regulates it, and call that agency. It would usually be the Department of Managed Health Care, at 888-466-2219 or , or the California Department of Insurance, reachable at 800-927-4357.

If you need help sorting through heaps of medical bills, you could hire a professional patient advocate, who will typically charge you a percentage of the amount they save you. To find patient advocates in your area, log on to

To see if you qualify for free assistance, try the Patient Advocate Foundation ( or 800-532-5274), which helps people resolve unaffordable health bills and also provides disease-specific, need-based financial aid.

This story was produced by , which publishes , an editorially independent service of the .

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Foster, who married into the family that owns Foster Farms chicken company, has Blue Shield coverage as well as a high-octane primary care plan that gives her 24/7 digital access to her doctor for a $5,900 annual fee that also covers her husband and two of their children.

Tiznado is from Nayarit, Mexico, and has no insurance. She gets free primary care visits and steep discounts on prescription drugs, lab tests and imaging.

But Tiznado, 32, and Foster, 48, go to the same place for their care: St. Luke’s Family Practice, in this Central Valley city of . St. Luke’s, a clinic with a staff of four in a nondescript shopping center, offers an unorthodox combination of concierge-style medicine for the well-off and charity care for the uninsured.

The annual fees that St. Luke’s collects from Foster’s family and some 550 other paying patients help cover free care for a somewhat larger number of uninsured patients, many of them, like Tiznado, Spanish-speaking immigrants who can’t get Medicaid because they lack documents.

The clinic does not accept insurance of any kind but requires its paying patients to have coverage for major medical expenses outside its scope of care.

The paying patients, whom St. Luke’s calls “benefactors,” say they are happy to participate in this “Robin Hood” model. It gives them highly personalized care with great access to their doctors and the emotional satisfaction of supporting those less privileged, the “recipients.”

Foster said it’s been a “huge, huge benefit” for her family to be able to text or call their doctor at any time and be seen on short notice: “Knowing that their group is here also to serve our community makes it all feel even more important.”

Tiznado, who visited the clinic one September morning for a scheduled monitoring of ovarian cysts, said St Luke’s “has helped us a lot — economically and in every way. I think if we moved somewhere else, I would continue coming here.”

But Tiznado and the other uninsured patients don’t get the same 24/7 access that benefactors do. The two groups used separate waiting rooms until the pandemic hit.

St. Luke’s is a local response to systemic U.S. health care problems including physician burnout, patient dissatisfaction and the fact that millions still lack care. , including 1.3 million undocumented people, will be uninsured in 2022, although the state is gradually expanding Medicaid coverage to . St. Luke’s is part of the movement for direct primary care, an alternative for doctors fleeing insurance-dominated medical groups.

Roughly 200 direct primary care practices start up each year in the United States, and there are currently of them employing an estimated 3,000 doctors, according to Dr. Philip Eskew, founder of , which provides resources for doctors who want to make the switch. That’s a tiny fraction of the primary care doctors in the U.S.

“We are indeed a small movement at this time,” Eskew said.

Their biggest challenges are regulatory. If the clinics take fees from people enrolled in Medicare, for example, their doctors must forgo Medicare reimbursement anywhere they practice. And some state regulators may consider direct primary care practices to be health plans and that make it difficult or impossible for them to operate.

Doctors in direct primary care typically charge patients a monthly or annual fee in exchange for enhanced access via phone, text or video, shorter wait times and longer face-to-face visits. And they generally don’t accept insurance, thus eliminating the need to chase bills and treatment authorizations.

“In my old practice, we spent almost half our time collecting payments. I thought if we could just get rid of all that overhead, we could spend more time with patients — and it proved true,” said Dr. Bob Forester, the conceptual father and co-founder of St. Luke’s, who retired earlier this year.

Many direct primary care docs scoff at the high-tech investor-owned firms such as One Medical and Forward Health. They are widely viewed as direct primary care companies, but critics say they are more focused on expanding volume than on offering personalized service.

“Direct primary care is where a physician has a relationship with a patient. We do not have to be accountable to an investor, because our investors are our patients,” said Dr. Maryal Concepcion, a family doctor in the remote mountain town of Arnold, California, who recently left a commercial practice to launch her .

St. Luke’s paid patients must have insurance to cover hospitalization, surgeries, specialty care, imaging and prescription drugs.

The clinic is often able to find steep discounts for its uninsured patients. For example, Quest Diagnostics charges them only 10% to 15% of its regular price for lab work, said Dr. R.J. Heck, one of the two family physicians at St. Luke’s and co-founder of the clinic. It often refers uninsured patients who need operations to , a reduced-rate surgery center in Bakersfield.

St. Luke’s recently got a $75,000 grant for imaging, lab tests, X-rays and some prescription drugs from the , a local foundation. And it works with several radiology groups that provide discounts, Heck said.

Tiznado, who needs periodic ultrasounds for her ovarian cysts, said she pays around $150 for them. “If I did it in another place, it would cost between $900 and $1,200,” she said.

St. Luke’s nonprofit tax-exempt status encourages donations, including from local corporate benefactors such as Foster Farms and winemaker E. & J. Gallo. Some workers at donor companies are among St. Luke’s uninsured patients.

Tax-exempt status also confers a benefit on paying patients: They can take a tax deduction on the portion of their annual fees they don’t use for medical care. Every year, St. Luke’s sends them a statement that puts a dollar value, based on Medicare prices, on the services they received.

Forester said St. Luke’s arose from his concern for the uninsured and his disdain for bureaucratic systems. But “the bottom line,” he said, “is that the idea for St. Luke’s came in an inspired moment of prayer.” He and Heck launched it over 17 years ago as a Catholic-inspired medical office.

However, while Catholic symbols adorn the walls of St. Luke’s, many of its patients are not Christian, and Catholic medical doctrine is not central to its practice.

“There’s nobody coming in here and looking or telling us what we should or shouldn’t do,” said Dr. Erin Kiesel, the clinic’s other family doctor.

Kiesel said she wouldn’t prescribe an abortion, but she would tell somebody where to go if they asked — which nobody has.

Heck and Kiesel took big pay cuts to come to St. Luke’s. Kiesel makes about $60,000 less a year than in her previous practice. Having more time with patients, less paperwork and better work-life balance more than offsets the lower pay, she said.

Patients cited the personal relationships they’ve built with their St. Luke’s providers.

Paul Neumann, a patient of Heck’s for 25 years who followed him to St. Luke’s, said that relationship has been a godsend.

He told of returning from a trip to Rome in 2009 with a case of walking pneumonia. When his wife called Heck the next morning, he came to the house immediately.

Neumann, 84, pays St. Luke’s well north of $10,000 a year for himself, his wife and his son’s family.

“I’d be happy to write a check twice as large,” he said.

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And he is more than ready for kindergarten.

Hand in hand with his mother, Martha Manzo, he walks into the Blind Children’s Center, a low-rise building nestled among apartment complexes in East Hollywood. In the brightly colored hallway, filled with paintings of animals, Manzo kneels to hug Christopher before he scurries unsteadily to his cubby.

“God take care of you and be with you,” she says. “And have fun.”

Born with congenital hydrocephalus that damaged his brain and left him with severely impaired vision, cognitive difficulties and a lack of coordination, Christopher hasn’t missed only school the past 18 months — he’s missed out on a host of vital occupational, physical and language therapies, as well as socialization with other kids.

At home, Christopher couldn’t look at a computer screen long enough to attend therapies or classes on Zoom, said Manzo, in an interview conducted in Spanish. “He would strain his eyes, look away, and his attention would falter,” she said. “He couldn’t devote the same attention as a kid without disabilities.’’

Christopher “could have advanced much more” since the pandemic hit if he hadn’t missed so much school, said Manzo, who is 36 and has three other children, ages 12, 10 and 8, whom she also has had to guide through months of home-schooling.

Yet the return to school raises particular health issues for Christopher and other children with disabilities who are at increased risk for serious bouts of covid-19, said his pediatrician at Children’s Hospital Los Angeles, . Though he isn’t immunosuppressed, Christopher has trouble coughing up secretions, which leaves him vulnerable to lung and respiratory infections, she said.

Compared with other adults in contact with children, his parents, teachers and therapists “have to be more vigilant about mask-wearing, hand hygiene and social distancing,” she said.

In short, Manzo was deeply worried about the threat of covid exposure Christopher faced at school. But it was a risk she felt he could no longer avoid, to get on with his life.

Trying to learn from home was “really hard on him,” Manzo said. “He couldn’t understand why he couldn’t go to school or the park or to his therapies.”

“I know covid is still among us, but I also can’t keep him at home like he’s a crystal bubble and protect him,” she said. “He needs contact with other kids and his teachers.”

The challenges faced by Christopher during the pandemic have been shared by many of the roughly U.S. children and young adults, ages 3 to 21, with special needs. Online platforms usually for them. For example, Christopher needs to feel Braille letters to read — he can’t do that on a computer screen.

Students with disabilities had “sort of this double hit where it was very hard to access school services and very challenging to continue to work on developing new skills,” said Dr. Irene Koolwijk, a specialist in developmental-behavioral pediatrics at UCLA Health.

It took a lot of preparation to get Christopher and the 40 or so other children attending the Blind Children’s Center back into the building of the private, infant-to-kindergarten school. All the children are blind or visually impaired, and most also have disorders ranging from autism and albinism to cerebral palsy and epilepsy. The school practices reverse mainstreaming, in which a few children with typical development share the classroom with children with disabilities.

Months before the school doors reopened, the center started teaching the students about wearing masks.

“Little by little, we started training the kids to wear masks on Zoom. It started off with the duration of a song, then two songs,” said Rosalinda Mendiola, adaptive services specialist at the Blind Children’s Center. “Our goal was that by the time we opened back up, they would be used to them.”

But it was difficult. Many children with special needs have a hard time wearing their masks and understanding the concept of distancing, said Mackintosh. Children with some forms of autism, in particular, have sensory issues that make it bothersome to have something on their faces.

“Children learn the most from modeling. They watch their parents, their teachers, their friends,” said Bianca Ciebrant, the center’s director of early childhood education. “But children who are visually impaired and blind can’t see the mask-wearing. That’s probably one of the harder barriers.”

It took Christopher seven months to start wearing a mask. “At first, he didn’t even want it in front of his face,” said Manzo. “He started to slowly accept it when he saw his siblings wear it.”

To reopen in September, the school also adopted new covid safety protocols. All 30 staff members are vaccinated, temperature checks are performed at drop-off, and parents aren’t allowed inside classrooms.

All students wear masks except for three of them who have limited motor ability and couldn’t safely remove a mask or don’t understand the mask-wearing process “and therefore it becomes sensory overload and behavior breakdown,” Ciebrant said.

There are six kids in each class, overseen by a teacher and two assistants. Christopher needs someone near him to remind him where to walk and to hold on to the banister for balance.

With so many staffers around, “creating a shield of vaccinated individuals around the child is important to making the transition back to school as safe as possible,” said Dr. Christine Bottrell Mirzaian, a pediatrician at Children’s Hospital Los Angeles.

Martha and her husband, Fausto Manzo, were vaccinated last March, and their 12-year-old daughter, Samantha, also has been immunized against covid.

“Our health is important to be able to continue taking care of him,” Martha Manzo said.

On a recent Wednesday, Christopher wore a teddy bear mask and a backpack to school. This is his last year at the center. When he started, he was only 2 and hadn’t learned to walk.

“He has received a lot of help,” Manzo said. “His movements have improved, and his communication skills.”

Christopher toddles around the playground during recess and greets his friends with a wave. “His balance is off, but he’s walking now,” his mother said. “I always wanted to see him run and explore.”

School staff members were happy to have their students back.

“We all felt this little warmth in our heart to hear their voices back in the hallway, whether it was crying or laughing or talking to their friends,” said Ciebrant. “This is what we’ve been waiting for, to hear those moments.”

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This <a target="_blank" href="/news/children-with-disabilities-face-special-back-to-school-challenges/">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;">