Tech startup company Fast Chief Communications Officer Jason Alderman (R) talks with an employee on the first day working in the office on March 24, 2021 in San Francisco, California.
Justin Sullivan | Getty Images
Inflation has stretched household budgets near their limit. As a result, most people have reined in discretionary spending, even when it comes to health and wellness.
But just as many Americans want to scale back, U.S. health officials are expecting another pandemic wave this winter and new research underscores the importance of having comprehensive medical benefits.
Although the Biden administration is looking at ending the public health emergency over the next few months, many who get sick but survive Covid suffer from enduring health problems, studies show. And currently, as many as 23 million Americans have what’s considered long Covid, according to recent estimates from the U.S. Department of Health and Human Services.
With open enrollment season in full swing, this is an opportunity to reevaluate your coverage, saidGary Claxton, senior vice president at the Kaiser Family Foundation, a nonprofit organization focused on national health issues.
More from Your Health, Your Money
Here’s a look at more stories on the complexities and implications of long Covid:
Employees spend 18 minutes, on average, reviewing their benefit selections during open enrollment, according to Rob Grubka, CEO of Health Solutions for Voya Financial. “They spend more time deciding what to watch on Netflix.”
But this year brings added uncertainty, he said. “Between rising inflation, Covid and long Covid, we underestimate how different things may look in the future.”
At the same time, more than a quarter of employees have postponed wellness visits and screenings and consider cost the most important factor in determining their benefit choices for next year, according to benefits platform Elevate.
Employees are making choices to keep themselves afloat, said Brian Cosgray, Elevate’s CEO and co-founder. Unfortunately, some are engaging in trade-offs — like foregoing needed medical care — that could cause problems down the road, he added.
To balance your overall health and the long-term risks of illness as well as financial constraints, Claxton suggests reassessing your employer-sponsored health insurance during open enrollment, which typically runs through early December.
Almost 159 million Americans rely on employer-sponsored health insurance coverage. Here are four key considerations with open enrollment season underway:
1. Health insurance plans
For starters, consider what your health coverage costs you.
On average, workers contribute $6,106 toward the cost of a family premium, with employers pick up the rest.
However, more workers have a deductible — the amount you pay before insurance kicks in — and that deductible is also rising. In 2022, the average single deductible was $1,763, more than double what it was a decade ago.
But “don’t just look at the monthly cost of your health insurance,” Cosgray advised. “Most employers offer a few health-plan options,” he added, such as a high-deductible plan with a health savings account or a more traditional PPO.
“If you expect your health-care costs to be low for the coming year, a high deductible health-care plan paired with an HSA could be a good way to save money,” he said. “However, if you have chronic health conditions in your household and typically hit your deductible, a traditional plan paired with [a flexible spending account] may save you more over the course of a year, even if the plan’s monthly cost is higher,” Cosgray said.
“If you are going to take the high-deductible plan, you have to be able to pay the deductible if someone gets sick,” Claxton added. “The plan maybe cheaper but what if you can’t afford to use it?” Most people can’t even afford a $500 expense, he noted. “If you go to the hospital the likelihood that your out-of-pocket costs are at least $500 are pretty high.”
There are often employer-offered resources designed to help pick between benefit offerings, which can include webinars and dedicated benefits professionals.
“Many health plans now have great tools to help you manage your choices based on what you anticipate your health-care costs to be,” advised Thomas Belmont, health and benefits practice leader at Gallagher.
In both cases, you use pretax money to cover out-of-pocket expenses, including doctor visits and prescription drugs.
To be able to use an HSA, you need to be enrolled in a high-deductible health plan, or HDHP. Contributions then grow on a tax-free basis, and any money you don’t use can be rolled over year to year.
“The opportunity to save and save efficiently is there,” Grubka said.
For 2023, employees and employers can contribute a total of up to $3,850 for individual coverage and up to $7,750 for family coverage, with an additional $1,000 as a catch-up contribution for those 55 and older.
Health FSAs have lower contribution limits — $3,050 for 2023, but you also don’t need to have a high-deductible plan in order to be eligible — in fact, you don’t need health coverage at all to sign up for one. Although, you may have to use the money by year-end or you lose it, with some exceptions.
3. Life insurance and disability insurance policies
To be sure, the pandemic brought a greater awareness of financial risks associated with a critical illness.
Employer-issued life insurance policies typically amount to a year’s worth of salary, often less, but that may be a fraction of what you need to protect young children or other dependents.
The same goes for disability insurance, which can help replace a portion of your paycheck if you get sick and are unable to work.
There are two basic kinds: Short-term disability generally replaces 60{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} to 70{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of your base salary and premiums are often paid by your employer. Long-term disability, which ordinarily kicks in after three months to six months, typically replaces 40{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} to 60{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of your income.
Other voluntary benefits offered through an employer can provide additional protection, including hospital indemnity insurance, critical illness coverage and accident insurance.
“As we go into next year and the additional financial pressures, make sure you are protecting your income,” Belmont said.
4. Wellness benefits
As a result of the pandemic, many more companies have expanded wellness offerings among the health-care coverage options to help employees deal with work-life stressors and personal issues.
“We’ve got a real crisis from an emotional well-being perspective,” Belmont said.
Employees should take full advantage of the services employers provide, often at no cost, also including financial coaching, emergency savings support, stress management classes and backup child care, he advised.
With rising prices causing more Americans to feel financially strained, “one of the most underutilized benefits is financial counseling,” Belmont said.
For decades, chemicals that make life easier — your eggs slide out of the frying pan, stains don’t stick to your sofa, rain bounces off your jackets and boots — have been touted as game changers for our busy modern lives. “Better things for better living … through chemistry,” was the optimistic slogan coined by DuPont, the company that invented the widely used chemical coating Teflon.
But this better living has come at a cost that is getting new attention. These chemicals — dubbed forever chemicals for their ability to last in the environment — are proving to have a lasting impact on human health. A growing body of research links the group of chemicals broadly known as PFAS, short for per- and polyfluoroalkyl substances, to conditions from unhealthy blood lipid levels to pregnancy complications to cancer.
Alarm about the health impacts of these chemicals has sparked a recent flurry of action from U.S. public health and regulatory officials. Warning that PFAS pose a greater health risk than previously thought, the U.S. Environmental Protection Agency in June dramatically lowered its recommended safe levels of the chemicals in drinking water.
“The updated advisory levels are based on new science, including more than 400 recent studies which indicate that negative health effects may occur at extremely low levels, much lower than previously understood,” Radhika Fox, assistant administrator of the EPA’s Office of Water, said in June at the Third National PFAS Conference, held in Wilmington, N.C.
Soon after, the National Academies of Sciences, Engineering and Medicine released the first clinical guidelines quantifying blood concentration levels of PFAS that could put someone’s health at risk. The 300-page report urges clinicians to recommend regular blood tests for anyone exposed to high levels of the chemicals and to provide information on how to limit exposure, such as installing special filters known to reduce PFAS in drinking water.
In the United States alone, by one measure, the tally in medical care costs and lost productivity from PFAS exposure linked to five medical conditions adds up to at least $5.5 billion annually, researchers at New York University reported July 26 in Exposure and Health. Those conditions include low birth weight, childhood obesity, hypothyroidism in women, and kidney and testicular cancers.
“We only looked at two of the more than 9,000 chemicals in the PFAS family, so we’re just seeing the tip of an iceberg,” says Leonardo Trasande, a pediatrician and environmental health expert at NYU Langone Health.
Ubiquitous chemicals
Among those most at risk of exposure are firefighters: PFAS make protective gear more water resistant, and the chemicals are found in a widely used fire suppressant foam. But most people have some measurable level of PFAS in their bodies, according to the U.S. Centers for Disease Control and Prevention. Exposure typically comes from ingesting PFAS-contaminated drinking water or food grown in soil treated with fertilizers made from sewage contaminated with the chemicals (SN: 11/24/18, p. 18). An estimated 2,854 locations across the United States have PFAS contamination.
“People and communities have had significant exposure to these chemicals. If they can ID that they are in an area of significant exposure, they should seek testing through their usual source of care,” says Ned Calonge, an epidemiologist at the Colorado School of Public Health in Aurora who chaired the committee that wrote the National Academies report. The committee linked PFAS exposure to a slightly different list of conditions than the NYU team, finding “sufficient evidence” linking PFAS to four conditions: poor antibody response to vaccination, abnormally high cholesterol levels, decreased infant and fetal growth, and kidney cancer. Evidence was “suggestive” for breast and testicular cancers, as well as thyroid problems and ulcerative colitis, an inflammatory bowel disease.
The report calls for more research into the health effects of PFAS, noting gaps in evidence on everything from neurological issues to bone density. These chemicals have a wide range of impacts on multiple systems in the body, Calonge says. And they’re “ubiquitous in the environment.”
Newer, not safer
PFAS have been produced in the United States since the 1940s. Because they are good at repelling oil and water, holding up at high temperatures and reducing friction, the chemicals became useful for a vast array of products, including carpeting, upholstery, food packaging and even dental floss. Yet, relatively few of the 9,000 or so versions of these synthetic chemicals have been studied for their toxicologic effects.
Many PFAS are now recognized as endocrine disruptors, chemical compounds that interfere with the normal functioning of the endocrine, or hormonal, system. But PFAS have other effects that can boost cancer risk, such as weakened immunity, excessive cell growth and altered gene activity. One study found a greater than twofold increase in kidney cancer risk between people with the highest versus lowest blood levels of one common PFAS called perfluorooctanoic acid, or PFOA, researchers reported in 2021 in the Journal of the National Cancer Institute.
A newer generation of PFAS was assumed to be safer because the chemicals are less likely to accumulate in the body. But these newer compounds are structurally similar to the older ones and can be just as harmful to health as their cousins, Trasande says. These newer molecules “are increasingly being associated with diseases like gestational diabetes. We’re just starting to see the bigger problem that might be at play.”
The EPA’s new drinking water advisory aims to tackle both old and new PFAS. It targets two of the earlier and most commonly found kinds of PFAS in the environment: PFOA and perfluorooctane sulfonic acid, or PFOS. The advisory reduces the level of drinking water contamination below which adverse health effects are not expected from 70 parts per trillion to 0.004 and 0.02 ppt, respectively. Those levels are based on routine exposure to them over a lifetime.
The EPA’s health advisory also provided the first-ever recommendations on two of the newer kinds of PFAS: hexafluoropropylene oxide dimer acid and HFPO ammonium salt, collectively known as GenX chemicals, and perfluorobutane sulfonic acid, or PFBS. The agency set the drinking water safety threshold at 10 ppt for GenX chemicals and 2,000 ppt for PFBS. These newer chemicals have similar persistence in the environment, the agency states.
Consumers can ask their municipal water provider for data on PFAS testing in their area. Testing is becoming more common, and providers should be able to list which PFAS they test for. Private wells can be contaminated with PFAS if they are near manufacturers that produce or use the chemicals, as well as airfields where PFAS are used for firefighting, firefighting training areas and some waste disposal sites. People with private wells near one of these facilities can get their water tested. The EPA is giving grants to help underserved small and disadvantaged communities provide household water quality testing and comply with drinking water regulations.
PFAS price tag
Because there are limited available data on the health effects of the newer generation of chemicals, the NYU and National Academies reports focused on the impacts of older PFAS.
First, the NYU team examined PFAS chemicals in blood samples obtained from roughly 5,000 adults and children who participated in the U.S. National Health and Nutrition Examination Survey. Then, based on earlier studies linking PFAS to certain diseases and models that estimate medical costs and lost worker productivity for these illnesses, the team came up with its PFAS price tag.
Childhood obesity, the largest contributor to the overall economic toll of PFAS exposure, costs about $2.7 billion a year, the team estimates, followed by hypothyroidism in women at $1.26 billion. When the researchers considered other PFAS-linked diseases beyond the top five, such as endometriosis, obesity in adults and pneumonia in children, the estimated economic burden rose to as much as $63 billion annually.
Assessing risk
The National Academies report focused in part on how to curb that toll by providing testing guidelines to clinicians to detect high levels of PFAS in the body and try to reduce exposure.
The report provides the first clinical guidelines on how to assess a person’s disease risk. A person with a PFAS blood concentration of less than 2 nanograms per milliliter doesn’t have to worry. But for patients with blood concentrations between 2 and 20 ng/mL, clinicians should screen for conditions like unhealthy levels of fat in the blood, which can lead to heart problems. Such screening is especially important for people more vulnerable to the effects of PFAS exposure, like children, pregnant people and those who are immunocompromised. For anyone who tests above 20 ng/mL, the report encourages routine screenings for some cancers, thyroid problems and ulcerative colitis.
“For almost 20 years, we’ve been able to measure PFAS in people’s blood, but there was no guidance to say what [those measurements] mean,” says National Academies report coauthor Jane Hoppin, who heads the Center for Human Health and the Environment at North Carolina State University in Raleigh. “For the first time, this actually sets some ranges, some guidance for what could be levels of concern, and what kinds of health follow-up might be appropriate.”
She hopes that the recommendations will increase testing availability and make both doctors and patients more aware of these chemicals and their health risks. The report also encourages doctors to work with their patients to figure out where they are being exposed to PFAS and how to mitigate those risks, by cutting down on PFAS-containing products and filtering water.
Activated carbon filters, found in some countertop or pitcher filters, don’t remove PFAS as completely as reverse osmosis filters, researchers at Duke University and North Carolina State reported in 2020. The National Academies report offers a link to NSF, a testing organization that offers technical details on which filters actually filter out PFAS.
Efforts like reducing PFAS in drinking water could help. While EPA’s health advisories are recommendations and not enforceable, Trasande is pleased that the agency acted quickly, particularly on newer chemicals like GenX. But he argues that in light of what we already know and are continuing to learn about the disease burden caused by these chemicals, PFAS should undergo more testing before they are approved. Better yet, they should be regulated by class instead of taking what he calls a whack-a-mole approach.
“Our environmental policy still takes a wait-and-see approach that we should wait 20 to 30 years, which is the time that people take to develop diseases due to chemical exposures,” he says.
David Goldhill is the chief executive of SesameCare.com, a digital marketplace for discounted health services.
The United States spends twice as much per person as other wealthy countries on health care. This fact is well-known, and when it is mentioned, people often point out that the governments of other developed countries leverage purchasing power to drive cheaper, more universal care. So why doesn’t the United States do the same thing?
Because we can’t. In fact, the do-what-everyone-else-does option is uniquely unavailable to us.
The world’s other health-care systems survive only because they receive a massive and ongoing, but hidden, subsidy courtesy of the inefficient U.S. system. Two unique features of our arrangement — the absence of price controls and the profit drive of doctors and hospitals — allow other countries to transfer the risk and cost of medical innovation to Americans.
And unlike in any other industry, once Americans have borne the costs of lifesaving breakthroughs as well as incremental improvements in tools and techniques, these can be used elsewhere at little extra cost. American exorbitance allows other nations to offer price-controlled universal care with none of the decline in quality, technology or productivity that would otherwise result from central planning.
A similar complaint has been made about the country’s defense alliance: U.S. allies ride free on American defense spending. Health care, indeed, is a kind of second NATO.
The United States can’t lower its costs by doing what other countries do, because what others do depends on our unique system remaining as is. Our only hope is to put in place more sensible economic structures that could introduce the competition that’s necessary to bring prices down.
The size of the U.S. health-care system is almost impossible to overstate. With barely four percent of the world’s population, the United States accounts for almost half of the world’s $8 trillion health-care economy. England’s National Health Service is tiny by comparison — barely bigger than U.S. Veterans Affairs health system funding. Canada’s total spending is comparable to the revenue of a single American company, United Health. Free-market star Singapore spends only as much as New Jersey’s Medicaid program.
The world’s top 10 spenders in pharmaceutical products
In 2020, the United States spent more on pharmaceutical products than all other nine spenders in the ranking combined.
All other top 9
countries combined
Notes: Prices are reported at the ex-manufacturer level (price when sold from manufacturer to wholesaler or direct to pharmacies). * Hospital market only. **Pharmacy market only.
The world’s top 10 spenders in pharmaceutical products
In 2020, the United States spent more on pharmaceutical products than all other nine spenders in the ranking combined.
All other top 9 countries combined
Notes: Prices are reported at the ex-manufacturer level (price when sold from manufacturer to wholesaler or direct to pharmacies). * Hospital market only. **Pharmacy market only.
The world’s top 10 spenders in pharmaceutical products
In 2020, the United States spent more on pharmaceutical products than all other nine spenders in the ranking combined.
All other top 9 countries combined
Notes: Prices are reported at the ex-manufacturer level (price when sold from manufacturer to wholesaler or direct to pharmacies). * Hospital market only. **Pharmacy market only.
This is why all health-care innovators — makers of drugs, devices, diagnostics, medical software — share the same business plan: Make money in the United States and take whatever scraps you can get in the other markets.
The pharmaceutical industry earns almost 50 percent of its worldwide revenue here, as do medical information-technology firms. Device makers earn 40 percent of their money in the United States. And this understates things, because U.S. revenue is generated from higher prices, so margins are greater. If the United States accounts for half of a company’s revenue, it probably contributes at least 75 percent of its profits.
America’s domination might not seem obvious. After all, high-tech health care exists everywhere in the world. Even in emerging economies, brilliant researchers, great universities and advanced companies perform cutting-edge research. Many have close relationships with their countries’ health-care systems, and some innovations are introduced in other nations. But the profit opportunity — the reason to invest — is always generated in the United States.
Consider the well-known miracle drug Gleevec. Before it came along in 2001, less than 30 percent of patients diagnosed with chronic myelogenous leukemia survived at least five years; today, 90 percent do.
Gleevec is also a poster drug for American dysfunction. Novartis steadily raised its price in the United States — even after its patent expired — to eventually reaching more than $123,000 per year in 2020. Yet, in Canada, Gleevec was priced at $38,000. A generic version in India now costs just $400.
Drugmakers and their opponents argue over the “fair” returns on innovation that companies need to maintain their incentive to invest in new medicines. Critics point to the share of pharma’s profits that come from barely legal anticompetitive behavior or from drugs created with heavy public support — such as the U.S. government’s $12 billion investment in coronavirus vaccines.
But enormous returns on a few blockbuster drugs compensate for drugmakers’ many unsuccessful products. That’s the business model, and these big, “unfair” returns are available only in the United States.
If the world’s largest health economy limited drug companies to “fair” returns — as other countries try to — then few new drugs would be created. The United States doesn’t pay $123,000 a year for Gleevec despite Canada paying only $38,000; Canada can pay $38,000 only because the United States pays $140,000.
And while pharmaceuticals might be the most obvious area in which the U.S. economy drives innovation, the $3.5 trillion we spend on care other than drugs makes an even greater contribution to world health-care advances.
In 2000, Intuitive Surgical Systems introduced the first commercially successful robotic surgery system. The company’s da Vinci robots carry $2 million price tags plus costly service contracts. In the first 20 years, 6,000 of the robots were sold worldwide, and American hospitals purchased roughly two-thirds of them.
Why? In the United States, the prices charged by hospitals and doctors are unrestricted. American physicians earn roughly two to three times as much as their counterparts in western Europe. Hospitals charge two to five times as much for their services.
The obvious, if rarely asked, question is: Why doesn’t competition bring U.S. health-care prices down? The answer: America’s stagnant third-party payment system allows hospitals and doctors to avoid competing on price. Instead, they compete on innovation. This is why hospitals advertise advanced, high-tech cancer therapies; surgeons build reputations for cutting-edge procedures; and even your family physician must invest to keep up.
Right now, we’re stuck. We want what every other country has. American reformers believe we’re just one clever policy tweak away from getting it — perhaps by instituting accountable care or “value-based” care.
But the only way to lower U.S. health-care costs is to rethink the system’s top-down policy structures that rely on huge, centralized payers.
What’s needed is a way to separate the safety net function that insurance provides from consumer decision-making. If insurance covered only major and unanticipated health problems, a consumer economy could drive competition in the rest of the system. This would give doctors and hospitals an economic incentive to bundle services, enhance efficiency, reduce waste and offer genuinely “value-driven” care.
In this century, the world has seen the democratization of many services considered “too complicated” for consumers — computers, finance, international travel, furniture construction, you name it. All this happened because people had enough control over their own spending to drive competition among innovators. It’s how industry managed to put supercomputer power in everyone’s pocket, while reducing price by 99 percent.
Until the same kind of competition is introduced in health care, the U.S. system will continue to subsidize the world — and cost us a fortune.
Silvia Garcia’s 14-year-old son was left permanently disabled and in a wheelchair after a community health center doctor in New Mexico failed to diagnose his appendicitis despite his complaint of severe stomach pain. The teenager’s appendix ruptured before he could get to a hospital, and complications led to septic shock.
Akimbee Burns had a Pap smear at a community health center in Georgia that showed abnormal cells. But she was not told of the results. About eight months later, she was diagnosed with cervical cancer that had spread to her lymph nodes. She died within two years, at age 38.
Rhonda Jones’ baby was left brain damaged after her Chicago-area medical team, which included community health center doctors, failed to perform an emergency cesarean section quickly enough even though Jones was at high risk for labor complications.
These three incidents — alleged in court documents as part of malpractice lawsuits that were settled without admission of wrongdoing — are among 485 payouts made nationwide involving community health centers from 2018 through 2021. The settlements and judgments totaled $410 million paid to the patients or their families, according to federal data released to KHN through a public records request.
But none of those health centers, and none of the doctors, paid anything. U.S. taxpayers picked up the tab.
The nation’s 1,375 federally qualified health centers, which treat 30 million low-income Americans, are mostly private organizations. Yet they receive $6 billion annually in federal grants, and under federal law their legal liabilities are covered by the government, just as those of the U.S. Department of Veterans Affairs and the Indian Health Service are. That means the centers and their employees can receive immunity from medical malpractice lawsuits and the federal government pays any settlements or court judgments.
As a result, the public is often unaware of malpractice allegations against those centers. The health centers and their employees are not named as defendants in the lawsuits, and the government does not announce when it pays to settle cases or court judgments.
In December 2016, Rhonda Jones gave birth to daughter Alayna via an emergency cesarean section.(Taylor Glascock for KHN)
“People should know if these doctors or centers are harming their patients,” said Deirdre Gilbert, national director of the nonprofit National Medical Malpractice Advocacy Association, a consumer advocacy group.
In addition, attorneys who have represented plaintiffs in lawsuits against health centers say federal rules handcuff patients with a short statute of limitations — two years — and do not allow punitive damages.
“The deck is stacked in the government’s favor,” said Regan Safier, a Philadelphia attorney who won a $41.6 million court judgment in 2018 in a case of a birth injury involving a community health center doctor.
Tragedies Hidden From View
From 2018 through 2021, the median payment for malpractice settlements or judgments involving health centers was $225,000, according to the data from the Health Resources and Services Administration, which oversees the community health centers. In 68 of the 485 payouts, the total was at least $1 million.
Many of the lawsuits against health centers involved allegations of misdiagnosis or dental errors. Most large awards were for birth injuries or cases involving children.
Silvia Garcia brought one of those cases. In December 2015, she took her 14-year-old son to First Choice Community Healthcare in Albuquerque, New Mexico, to be treated for severe stomach pain and fever, according to a lawsuit she filed against the government.
The doctor felt the boy’s abdomen but ordered no diagnostic tests, the family alleged. The physician advised Garcia to take the boy to the hospital if his pain worsened.
Two days later, she took him to a hospital emergency room. There, doctors found that his appendix had ruptured. He had developed septic shock that led to brain damage and acute injury to his kidneys.
The teenager was hospitalized for eight months.
Garcia settled the case for $6.8 million, most of which went into a special fund that can be paid out for future medical expenses.
First Choice and Garcia declined to comment. The government said the settlement was not an admission of fault.
Community health centers pushed for — and won — government malpractice protection in the 1990s. They argued their revenues were limited and malpractice insurance would divert money that could better be used for patient care.
The centers differ from other health clinics because they get a federal grant each year. They also receive higher reimbursements from Medicaid and Medicare than do private doctors. In return, the centers are not allowed to turn anyone away, and the fees charged to low-income patients are on a sliding scale. Nearly half of the centers’ patients are covered by Medicaid, and 20{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} are uninsured.
Malpractice lawsuits are a risk for all health care providers and are just one barometer of quality of care. The settlements and court judgments against the health centers don’t measure the clinics’ overall performance.
Even lawyers who have sued on behalf of health center patients acknowledge the importance of the facilities. Rhode Island plaintiff attorney Amato DeLuca said that the health centers serve a vital role in the health industry and that he had found “a lot of really wonderful, extraordinarily capable people that do a really good job” at the centers.
Yet everyone must be held accountable for mistakes, DeLuca said.
Akimbee Burns’ case is an example of a missed diagnosis, according to the lawsuit she filed against the U.S. government. Burns, who made $11 an hour at a utility company, had a Pap smear in 2016 at South Central Primary Care Center, a community health center in Ocilla, Georgia. The test results showed abnormal cells, but she was not informed of the results, according to the complaint. She inquired about the test several times in the following months but still was not informed about the results, she alleged.
About eight months later, the staff at a different health care facility diagnosed advanced cervical cancer. She filed a lawsuit alleging the community health center had been negligent. She underwent radiation and chemotherapy. But she died in April 2019, leaving behind two children, including one minor.
South Central Primary Care Center did not respond to requests for comment, and the government denied any wrongdoing.
Roadblocks for Patients
A patient alleging medical malpractice by a health center must first submit claims to the U.S. Department of Health and Human Services for review. The government can make a settlement offer or deny the claim. If the claim is denied or not settled, or a six-month review period expires, the patient may sue in federal court under the Federal Tort Claims Act, or FTCA.
To get that federal protection, health centers must have quality improvement and risk management programs and must show regulators that they’ve reviewed the professional credentials, malpractice claims, and license status of their physicians and other clinicians.
“There are rigorous safeguards in place to ensure that health center grantees are in compliance and that patients are getting the very best care,” he said. “FTCA makes health centers more vigilant on quality and not less.”
About 86{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of community health centers were covered under the FTCA for medical malpractice coverage as of September, said Christy Choi, a spokesperson for the Health Resources and Services Administration.
She said the government has implemented “robust quality improvement and patient safety efforts” as part of the program.
The system makes collecting damages more difficult for patients than if they went to state courts for malpractice suits, said attorneys involved in cases against health centers. In addition to the prohibition against punitive damages, such cases are decided by federal judges instead of juries. The lack of a jury is important, they added, because judges are less likely to be swayed by emotion and that can mean lower dollar amounts in the awards.
Plaintiffs are also at a disadvantage because the federal government has unlimited resources to defend cases, unlike the patients and their attorneys, said Christopher Russomanno, a Miami attorney.
“These cases cost hundreds of thousands of dollars for us to get ready for trial,” said Jack Beam, the Illinois attorney who represented Rhonda Jones. “Our record was $900,000 in case costs.”
Rhonda Jones smiles at daughter Alayna. (Taylor Glascock for KHN)
All these factors can make finding a lawyer an obstacle for patients.
Deborah Dodge, a Missouri lawyer, said some attorneys are reluctant to take the cases because the government caps their fees at 25{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of the settlement amount. In contrast, plaintiff attorneys often take about 40{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} in successful state court malpractice cases.
Rhonda Jones was one of those who received a settlement. Her baby was transported to a children’s hospital soon after being born by emergency cesarean section at West Suburban Medical Center in the Chicago area in December 2016, according to her lawsuit. The baby, Alayna, was treated for brain damage from a lack of oxygen, and she now has cerebral palsy.
Jones showed signs of a high-risk delivery when she arrived at the hospital nearly 39 weeks pregnant: She was 40 years old, this was her 11th child, and she had severe preeclampsia and possibly gestational diabetes.
Her lawsuit alleged that she was not adequately monitored at the hospital and that surgery was not performed in time to prevent injury to Alayna.
Jones agreed to a $21 million settlement, $15 million of which was paid by the federal government because some of the doctors involved were employed by PCC Community Wellness Center. The health center and the hospital declined to comment. In court filings, the government and hospital denied wrongdoing.
The money — most of which is in a trust overseen by the court — provides for Alayna, who will require care throughout her life.
“Before what happened to Alayna, I loved them,” Jones said of the health center where she had gone for several of her previous pregnancies. “They were great for me because they would be open late at night when I was working.”
“I still would tell someone to go to PCC because maybe they will get the right doctors when they go to have their baby,” Jones added.
Alander Rocha and KHN reporter Colleen DeGuzman contributed to this article.
When you look at the numbers, it’s easy to gape in horror.
In Ghana, a nation of 32 million people, there are only 62 psychiatrists.
Zimbabwe, with a population of 15 million, has only 19 psychiatrists.
And in Uganda, there are 47 psychiatrists serving a country of 48 million — less than one single psychiatrist for every million people.
These are staggering ratios. To get your head around them, take the US as a comparison. There are around 45,000 psychiatrists for all 333 million Americans, which translates to about 135psychiatrists for every million people. That’s still not enough — experts are actually warning of an escalating shortage — and yet it’s a whopping 135 times more coverage than exists in Uganda.
These numbers have very real, and sometimes very brutal, implications for people’s lives. When psychiatry and other forms of professional mental health care are not accessible, people suffer in silence or turn to whatever options they can find. In Ghana, for instance, thousands of desperate families bring their ailing loved ones to “prayer camps” in hopes of healing, only to find that the self-styled prophets there chain their loved ones to trees. Instead of receiving medical treatment for, say, schizophrenia, the patients receive prayers.
The scandal of mental health care in developing countries has been well documented, and surveying it, you could be forgiven for thinking the solution is straightforward: These countries just need to train more psychiatrists and mental health professionals of the type you’d find in the US.
But that’s too simplistic. Yes, training more mental health specialists will be part of the answer for these nations. But what’s most interesting is that developing countries have also figured out a new way to tackle the deficit in mental health care — and it could hold lessons for the developed world as well.
Specifically, these nations have been serving as a proving ground for a model called community-based care, where non-specialist providers or lightly trained laypeople — picture someone like your grandmother, not a doctor — deliver brief mental health interventions in informal settings like homes or parks.
Whereas importing Western norms can alienate local populations, who may not view mental health problems as medical, brain-based problems, community-based care has found acceptance because it pays attention to cultural context. Lay counsellors meet patients where they are — both literally, in terms of physical space, and conceptually, in terms of their beliefs about mental health.
This model has turned out to be not only cheap to operate and easy to scale, but also incredibly effective for treating issues like depression. So effective, in fact, that the model is now being exported to the US, which stands to learn a lot from these poorer countries.
Dixon Chipanda, psychiatrist and founder of the NGO Friendship Bench, visits with his grandmother. He says she was part of his inspiration for the benches project.Brent Stirton/Getty Images
In 19th-century Europe, the reigning paradigm of mental health care was the asylum. The belief was that people suffering from psychiatric conditions should be institutionalized and treated on an inpatient basis. As Europeans exported this belief to the territories they colonized, asylums sprang up everywhere, from Ghana to India.
By the middle of the 20th century, asylums were becoming discredited: They were too often sites of coercion and violence, not to mention notoriously overcrowded and unhygienic. At the same time, the discovery of new psychiatric medications fostered hope that patients could be treated on an outpatient basis. In Europe, many asylums shut down.
In Accra, the capital city of Ghana, a psychiatric hospital built on this model in 1904 still houses hundreds of patients, some voluntary and some involuntary. Their issues range from depression to psychosis. It’s a resource-strapped, overcrowded institution. When I visited the hospital in 2019, I found that some patients sleep outdoors in a courtyard, where a motley collection of beds draped in mosquito nets was scattered around.
Thinking about the legacy of colonialism helps explain why this warehousing of the mentally ill persists, explained Vikram Patel, a psychiatrist and a professor of global health at Harvard Medical School.
“When the Europeans left Africa, Asia, and Latin America, they left virtually no higher education infrastructure for the native people. Basically, the colonizers left nothing,” he said. Upon gaining independence, some postcolonial countries had just one medical school for the whole nation. “And if psychiatrists can only be trained in medical schools, well, then, you know. There’s nothing.”
The very limited training capacity — and very limited funding to increase that capacity — has led to a supply-side problem. Today, that problem is aggravated by a major brain drain: The few who do train in psychiatry tend to move to richer nations offering them a more comfortable life.
And most would-be doctors in Africadon’t want to specialize in psychiatry. For some, that’s because it’s associated with institutionalization or incarceration. Others, aware that their cultures stigmatize mental illness as the work of evil spirits, may fear being viewed as “tainted” by contact with mentally ill people. And this stigma creeps all the way up to the policymakers debating how to allocate scarce resources.
“We bring these stigmas into the boardrooms and into decisions we make around fiscal planning,” Tina Ntulo, who leads the mental health nonprofit StrongMinds in Uganda, told me. “You do not budget for a person who you think is cursed or bewitched.”
Many would-be patients are also hesitant to see psychiatrists, who represent a foreign idea.
“People just don’t conceive of their mental health problem as a biomedical problem,” Patel said. “They do not say ‘I feel the way I do because I have an illness in the brain.’ That is exquisitely uncommon.”
And in cultures that don’t view mental health problems through a medical lens, stigma is a major barrier to seeking out professional care. In one large-scale survey in Nigeria, for example, 83 percent of respondents said they would be afraid to even have a conversation with someone with a mental health problem. The social costs of being branded as mentally unwell are just too high.
This is part of why some developing countries are moving toward community-based care. When you receive care from someone who’s familiar and helps you without necessarily applying a diagnostic label, it can mean there’s less stigma.
Despite being a psychiatrist himself, Patel does not believe the answer to the mental health care deficit is to just train more doctors like him. Instead, he’s become one of the most influential advocates for community-based care, where people with just a bit of training — weeks or months, not years — offer focused therapy. Empowering non-specialist providers or laypeople to take on tasks formerly done by specialists is what the World Health Organization refers to as “task-shifting” or “task-sharing.”
You might think that therapy delivered by a layperson is fine for countries that can’t afford more mental health professionals, but certainly not the ideal. Yet Patel and others who embrace the community-based model are making a much more radical claim.
“A lot of people think this is just a stopgap arrangement. It’s not,” Patel told me. “In the US itself, you need community health workers. What we need in all countries is the same model. We need to have an army of community-based health workers, nurses, social workers, delivering evidence-based interventions.”
And they are, in fact, evidence-based. Over the past two decades, dozens of randomized controlled trials (RCTs) and other studies have come out in favor of the community-based model.
Friendship Bench offers a prime example of what community-based care can look like. Rather than expecting people who are mentally unwell to seek out a psychiatrist’s office, this Zimbabwean nonprofit recruits “grandmothers” — middle-aged or older women who help out in their communities — to learn enough about depression and anxiety to recognize them, and then to treat those disorders using problem-solving therapy. That’s exactly what it sounds like: a therapy that teaches people the skills to devise their own solutions to the problems they face.
Each grandmother, recognizable in her uniform, will then go sit on a bench in a yard. People come along, wanting to talk. In fact, since Friendship Bench was created in 2006, more than 1,600 grandmothers have been trained, and they’ve already served more than 158,000 people — to great effect.
Friendship Bench counsellors attend a Sunday service at the Catholic church in Msvingo, Zimbabwe. The NGO offers free mental health counselling through trained grandmothers who work as lay health workers in clinics.Brent Stirton/Getty Images
In a 2016 study, 573 patients were assigned to either a Friendship Bench or to a bolstered version of standard psychiatric care available in Zimbabwe, which includes antidepressants. Six months later, only 14 percent of those who’d sat with a grandmother were still depressed, compared to 50 percent of those in the standard care group.
Another great example can be found in Uganda and Zambia: StrongMinds, a nonprofit founded in 2013, trains laypeople to lead group talk therapy sessions as a way to treat women with depression. Over a 12-week period, the women learn to identify the triggers of their depression and devise strategies to overcome them, using a form of therapy called group interpersonal therapy.
“This therapy is culturally appropriate. It sees interpersonal relationships as the treatment for depression,” said Tina Ntulo, the country director for Uganda. “And on this continent we are still highly relational and dependent on each other.”
Working with laypeople has enabled StrongMinds to scale up quickly, reaching more than 160,000 women to date.
“One of the amazing things our staff found is that the village volunteers [who’ve been trained to deliver the therapy] are so much better at mobilizing the women to come for therapy,” Ntulo told me. “Our staff said they never saw such high attendance for therapy when they were running it.”
Two RCTs have demonstrated that this intervention is both powerful and cost-effective. Independent researchers estimate that StrongMinds prevents the equivalent of one year of severe major depressive disorder for a woman at a cost of $248 — a pretty good deal, especially when you consider this helps the woman as well as her dependents.
Such interventions have spillover effects. The researchers note that mental health care can lead to material benefits: A non-depressed woman is more likely to be able to work, earn income, and get her kids to school so they can one day work and earn income, too.
A third example of community-based care can be found in India, where Patel co-founded an organization called Sangath. It developed a six-session program in which lay counselors treat patients with severe depression. The program showed strong results, leading to significantly lower symptom severity and higher remission than in a control group after three months.
But what’s really amazing about it is that, a full five years after researchers conducted the initial trial in India, a followup still showed significant differences between those who had received the treatment and a control group. The benefits, it turned out, could really last.
Right about now, you may be thinking: This laypeople stuff sounds all well and good for people dealing with common mental disorders like depression or anxiety, especially if they’ve got mild cases, but some people need an actual psychiatrist.
Even ardent proponents of community-based care agree with that.
“You need some psychiatrists. There’s no question that they play a role,” Patel said. That can be true even when it comes to the common mental disorders: After all, though Sangath’s community-based program for treating depression in India showed strong results, about a third of participants remained depressed after the program.
So the claim is not that community-based care should replace psychiatry. It’s that making mental health care primarily the business of psychiatrists, with little room for alternative approaches depending on context, is a mistake.
Of course, achieving the right balance between the two models is tricky.
At StrongMinds, Ntulo is very clear with the laypeople being trained about what is and isn’t within their remit. “When a person’s symptoms fall outside depression, this is not your client,” she said. “So you refer the person to the health center, and a clinician there will assess.”
At a health center, some of the tasks reserved in the West for a psychiatrist have been shifted to nurses. They can prescribe certain medications, for instance. They consult a flow chart that makes it easier to assess a patient — is he hearing voices or not? — and when symptoms indicate the patient’s problem is beyond their capacity, the nurses refer him to the next level of care above them. Essentially, laypeople handle the easier cases, nurses handle somewhat more complex cases, and the really complex cases may be referred to a psychiatrist for treatment.
StrongMinds is not anti-medication on principle, but doesn’t dispense it — partly because current-generation psychiatric medications are less available in developing countries like Uganda, and partly because much of the population would balk at the idea that a mental health condition is something they should treat with medication. Instead, StrongMinds uses the methods it thinks are most effective for the context.
It’s a system that makes sense to Ntulo, who says only a minority of people need a psychiatrist. “Everybody else could actually receive services through talk therapy and they’d probably be able to stay well for a long time,” she told me.
Patel agrees. He estimates that community-based care could probably address 80 percent of mental health morbidity. “The irony is that 80 percent of the money that’s being spent — this is my back-of-the-envelope calculation — is for that 20 percent that need hospitalization,” he said. “I think the real problem is that we do not spend enough at the base of the pyramid.”
Kwabena Kusi-Mensah, a Ghanaian psychiatrist, is a little skeptical about how far community-based care can go. “On paper, it’s a brilliant idea, really fantastic,” he said. “But having watched it be implemented for over 10 years now, there have been serious problems and challenges.”
Ghana, he explained, has trained a lot of mid-level staff called community psychiatric officers. These CPOs are like physicians’ assistants who’ve been given some additional training in psychiatry. The idea was that they would work in small villages or towns, to help bridge the treatment gap there.
In reality, the CPOs have drifted into major urban centers; now that they’ve got specialized training, they want to use it to secure a better life for themselves. But what’s even more worrying to Kusi-Mensah is that some of them are going over and above what they’ve been trained to do. He worries that this overreach could put patients at risk — if, for instance, they try to treat problems they’re not qualified to treat.
For that reason, he actually prefers task-sharing of the sort that Friendship Bench does with its grandmothers. “These are not medical people,” he said, “so they are less likely to overreach and do things they’re not supposed to do.”
A carpenter works on a bench near a Friendship Bench site.Brent Stirton/ Getty Images
When it comes to tasks that require medical know-how, he’d prefer to see psychiatrists in place to handle those, not mid-level staff. And he told me he’s “hyped up psychiatry” to many young medical students, enticing them to enter the field. But he’s careful not to entrench himself too much in either a pro-psychiatry camp or a pro-community-care camp because he doesn’t want to become too ideologically attached to one or the other.
“With extremes of ideology, if you lean too much to one way or another, you end up in a ditch,” he said. “So stay in the middle of the road, is the way I think about it.”
What all these community-based programs, and others in a similar vein, have discovered is the power of getting local laypeople to meet folks where they are.
Kusi-Mensah emphasized that importing Western norms just doesn’t work: If you want to help people in a place like West Africa, you can’t discount the importance of traditional beliefs, including religion.
“In our cultural background, where things are overspiritualized, our biggest competitors in mental health provision are the prophets,” he told me, referring to those who profess to heal patients with prayers, like in Ghana’s notorious prayer camps.
Efforts are now underway to work with, not against, faith-based healers to improve care. Some mental health professionals have gone to the prayer camps and introduced medications as a complementary treatment. Instead of saying “prayer doesn’t work, take this pill instead,” they might encourage prayers to be said alongside medical treatment. This type of collaboration has resulted in improved clinical outcomes for the patients.
But working within the camps is controversial because it could give the appearance of condoning them. Less controversial are efforts to partner with religious leaders in various towns and villages. Pastors and imams often double as informal mental health counselors anyway — that’s true in the US, too — so, the thinking goes, why not view them as another cadre of laypeople who can be trained? And for mental health problems that are beyond their ken, why not establish a referral pathway between them and the mental health care professionals?
“I’m a bit of a pragmatist,” Kusi-Mensah told me. “So I think the best we’re going to get is this sort of rapprochement, where it’s like, ‘Okay, there’s a spiritual component, so let the pastor handle that, but also there’s a medical component, so the doctor will handle that.’”
Western nations like the US favor a biomedical and highly individualistic view of mental health. Compared to, say, a Ghanaian, an American is more likely to conceive of her mental health problem as a brain problem and seek out medication from a psychiatrist. And she’s got a far better chance of accessing one.
Yet Americans’ mental health is in such bad shape that the US Preventive Services Task Force recently recommended that doctors screen every patient under 65 for anxiety. And 90 percent of American adults say the US is experiencing a mental health crisis, according to a new poll from CNN and the Kaiser Family Foundation.
To Patel, this indicates that the biomedical system can’t be the whole solution. “Mental health care is inadequate not because there’s not enough psychiatrists in most countries,” he said. “If that was the case, the US should have a perfect system. But it has a huge number of problems. It is living proof that the problem isn’t only about the lack of psychiatrists.”
America once flirted with the idea of community-based care. As Vice explained:
It’s taken a few decades, but America now seems ready to experiment with community-based care again as a supplement to psychiatry. What’s exciting is that, this time, it’s taking inspiration from poorer countries.
Zimbabwe’s Friendship Benches have made their way to New York City. Walk around Manhattan and you might see a trained layperson sitting on a big orange bench, waiting to listen or talk about issues ranging from depression to addiction. These are issues some of the laypeople have experienced themselves, so they’re nonjudgmental. They literally meet people where they are, lugging their bench around from spot to spot, as part of the Thrive NYC program aiming to create a mental health system that works for everyone.
India’s Sangath program for depression, meanwhile, is now being rolled out in Texas, where Patel is collaborating with the Meadows Mental Health Policy Institute and Baylor Scott and White, the largest not-for-profit health care system in the state.
And this year, Uganda’s StrongMinds is setting up a pilot in New Jersey. The idea is to address the US mental health gap by reaching people who can’t afford to pay for a licensed professional, with a focus on serving Black people, Indigenous people, and people of color.
“We just finished training the team in New Jersey!” Ntulo told me. “They’re going to use the same model we use. It’s an amazing solution for a health system that is so commoditized, like yours.”
Unsure where by to go for assistance, a homeless one mom named Mary designed an important contact immediately after she had a newborn in 2020. She dialed 211, a social provider hotline that place her in contact with transitional housing.
Even though she was doing the job two positions, Mary, who declined to give her last title, couldn’t pay for each hire and boy or girl treatment. But 211 operators in Lake County hooked her up with YWCA child treatment, monetary aid for a safety deposit, 3 months’ rent, and a landlord who’d acknowledge both equally.
“I by no means would have recognized if I did not contact 211,” Mary stated in a video job interview with United Way, which can help sponsor the support. She now has a one secure career and a household. “I sense like 211 … has served me tremendously.”
A comparable 211 company has just lately appear to DuPage County, and additional are prepared to launch early subsequent 12 months — probably on Feb. 11 — in Chicago, suburban Cook County, and Kendall County. 211, like the improved recognised 911 for emergencies and Chicago’s 311 for metropolis providers, puts callers in touch with nonemergency well being and social products and services.
Phyllis Gary, an ingestion and referral specialist with the new 211 hotline in DuPage County, responses calls on Nov. 17, 2022, in Wheaton. The new 211 social service hotline lately started in DuPage County. (Stacey Wescott / Chicago Tribune)
The most common providers are enable shelling out hire and utilities, but they also incorporate free and confidential disaster counseling, disaster guidance, food items pantries, overall health treatment, insurance plan, employment, and veterans products and services.
Kane, Lake, McHenry, and Will are amongst the many counties that present the support in Illinois. As a whole, the point out lags behind the rest of the country in utilizing the hotline, with almost fifty percent of its counties continue to without.
But as soon as Chicago and Kendall appear on-line early upcoming year, practically 90{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of the state’s populace will be protected.
In DuPage, the second most populated county in Illinois after Cook, officers established apart $1.6 million in federal American Rescue Approach Act money to fund the plan for the first a few years.
The round-the-clock, multilingual phone lender will be operated by Addison Consolidated Dispatch Middle, which also provides 911 dispatch products and services, County Board Chairman Dan Cronin claimed.
“We are thrilled to introduce however another ingredient of DuPage County’s solution of strengthening our social services safety net,” Cronin stated.
Anticipating elevated desires for the duration of and following the COVID pandemic, DuPage officials also have delivered tens of millions of dollars in funding to beef up the county’s social solutions. That included buying and transforming a previous Red Roof Inn in Downers Grove for PADS to use as a homeless shelter.
Expenses change by county. Kane County, whose services is presented by Path, has an annual spending budget of about $86,000. The additional populous Lake County, which has dealt with 150,000 calls in a few a long time, has a spending plan approaching $500,000, with funding from the county, local governments, foundations and personal contributors.
Phone calls have elevated noticeably since the onset of the COVID pandemic. Apart from the mobile phone hotline, persons can entry services in quite a few counties via 211 web-sites. Past yr, Lake County counted more than 57,000 contacts with 211 — most of them on-line.
But it generally can help to communicate to a 211 operator, United Way of Lake County spokeswoman Lori Nerheim stated.
“The reward of speaking to another person is they are trained navigators to get to the root of the need,” she stated. “Many men and women may simply call with one particular need, say housing, but it may well be result of domestic violence, or there might be a food have to have. Getting another person to guideline you is genuinely important.”
Also using federal American Rescue Strategy resources, Kendall County has budgeted $136,000 for its software by way of 2025, county Administrator Scott Koeppel mentioned. Outgoing County Board Chairman Scott Gryder aided to set up the system as a result of a nonprofit agency, Koeppel stated.
The up coming action is to make certain persons know about the amount. Only 21{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of Lake County people realized about the 211 provider in a current county study.
“Ultimately, we want it to be as memorable as 911,” United Way of Lake County President Kristi Extended claimed.
DuPage County board member Julie Renehan claimed officers hope 30,000 to 40,000 calls for aid a year.
“211 meets genuine requires in actual time,” she mentioned. “It’s the quantity to call when you don’t know who to connect with. This is a person we can all be proud of.”
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