By Rachel Crumpler

After graduating from a medical school in the Northeast, Caledonia Buckheit came south to Duke University Hospital to complete her obstetrics and gynecology residency. She finished up last June and found work in North Carolina — ready to provide comprehensive reproductive health care to patients, including abortion.

Just weeks after finishing, the Supreme Court overturned Roe v. Wade. The June 24 decision in Dobbs v. Jackson Women’s Health Organization eliminated the constitutional right to abortion that had existed for nearly half a century.

“Controlling women’s bodies has always been a topic but I didn’t really think it would get to this,” Buckheit said.

Suddenly, working in reproductive health care got a lot more complicated. 

The Dobbs decision handed the authority to regulate abortion back to states and their elected officials, ushering in a seismic change in access to the procedure nationwide. Lawmakers in dozens of states — including North Carolina — pursued greater restrictions.

On top of the challenges that come with entering a new profession, Buckheit — like everyone else working in reproductive health care — has spent the past year navigating a shifting legal landscape and all the questions and unknowns that come with continuing to provide care.

It’s a dynamic that will continue to be part of the job for the foreseeable future as North Carolina’s new restrictions limiting most abortions after 12 weeks take effect July 1 and access to the abortion pill mifepristone is being contested in court.

“It’s just been really disheartening, feeling like my patients have less autonomy,” said Buckheit, a general OB-GYN working at a private practice in the Triangle.

Adjusting practice

Even for those who have been practicing for years, like OB-GYN Amy Bryant, it’s unquestionable that the past year has been the most challenging and exhausting time to be in the reproductive health care field.

Since the fall of Roe, the legal landscape has been continuously shifting. Abortion providers across the nation and in North Carolina have had to adjust their practices to stay within the bounds of the law.

“When I think back to the early days after the Dobbs decision after Roe v. Wade was overturned, I just really think about the chaos and the uncertainty and the difficulties that we confronted, like, almost instantaneously with this new law of the land,” Bryant said. “It was truly just kind of scary.” 

Beverly Gray, another long-time OB-GYN who works with many high-risk and complicated pregnancies, said she was startled by how quickly some neighboring states took action to cut access to abortion. For months, North Carolina — and its 14 abortion clinics located in nine counties — became a critical abortion access point in the Southeast, providing care to an increased number of out-of-state patients.

In August, North Carolina physicians had to adjust their practices for the first time following the Dobbs decision when a federal judge reinstated North Carolina’s 20-week abortion ban, citing the disappearance of constitutional protections on the procedure. The ruling cut the window of time pregnant people had for seeking abortions in the state from fetal viability, which typically falls between 24 and 26 weeks of pregnancy. 

The loss of those weeks was palpable for abortion providers like Gray who had to turn patients beyond 20 weeks away — patients she could previously care for. In her practice, she said those patients mainly consisted of people who received a diagnosis of severe birth defects. 

Then it was a waiting game. Republican state lawmakers expressed their intentions to pursue greater restrictions on abortion shortly after Roe was overturned, but no one knew the speed at which they would move or what if any restrictions would entail. 

The uncertainty spanned many months.

“We didn’t know when the law might change and how we were going to respond if somebody was already scheduled and ready to go and they’d come from eight hours away,” Bryant said. “We didn’t know if we would still be able to care for them or not. That was just not a good way to practice medicine.” 

Ultimately, North Carolina lawmakers brushed aside medical providers’ pleas against adding more restrictions this past May. They passed a ban on the procedure after 12 weeks with exceptions for rape, incest, fetal problems and risk to the mother in May, and overrode a subsequent veto from Gov. Roy Cooper.

Next month, once again, a change in law will necessitate people who work in reproductive health care to alter their practices to conform to new constraints on their work.

Even a month after Senate Bill 20 was passed and the veto overridden, there are still more changes, as just this past week, the state Senate added an amendment to a separate bill that clarifies some of the timing of restrictions.

Gray said it’s not normal for physicians to have to significantly rethink how they practice, especially so many times over the span of one year. She emphasized that practice changes are being dictated by an arbitrary change in law, not as a result of improved medical guidelines.

“It’s completely disruptive to our practice, to our lives, to our day-to-day,” Gray said.

‘Exhausting on so many levels’

In addition to Gray maintaining a busy schedule providing patient care, the year has been full of trips to the legislature to voice opposition to increased abortion restrictions, conversations with lawyers to understand new rules, internal meetings to adjust practices to be legally compliant and media interviews explaining what changes mean to the public.

She’s even filed a federal lawsuit along with Planned Parenthood South Atlantic challenging several provisions of the new state law banning most abortions after 12 weeks, arguing they are unclear or unconstitutional.

It’s a heavy load to carry — added stresses and tasks that Gray said most other physicians don’t have to experience.

“It’s really just exhausting on so many levels because I’m doing all that and at the same time still providing care, still doing all the other work that’s required as a physician and now it’s just all these extra layers,” Gray said. 

When Gray decided to go to medical school, she never thought her role as an OB-GYN would involve so much advocacy and parsing new laws, but that’s what it’s turned into in the post-Dobbs period.  

Bryant agrees that the role has changed significantly over the past year.

“I have spent so much time poring over the legal issues related to my work,” she said. “It is not what I would like to be doing. 

“I think that pregnancy is just far too complicated to be legislated. And when nonmedical professionals start to try to legislate it, it becomes even more complicated to really understand the nuance — to be able to address the nuances in the individual situations that arise when a person becomes pregnant. This is not in any way what I expected my life to become.” 

Buckheit, the new OB-GYN, didn’t expect lawmakers would be dictating how she can do her job, either. And she believes they may have written the law differently if they interacted with pregnant patients on a daily basis.

“I truly feel that if lawmakers spent a week at Planned Parenthood or spent a week in a high-risk OB-GYN office, they would have a really different take,” Buckheit said. “There’s so much complexity and nuance to what we see and what patients and families are going through.”

For example, she’s had to read the state-mandated counseling script 72 hours before an abortion to patients whose babies have serious fetal anomalies.

“It’s like, adoption is an option, parenting is an option,” Buckheit said. “I’m saying this to someone whose baby doesn’t have a brain. It’s just so cruel.” 

The work, particularly in an environment of tightening restrictions, also takes an emotional toll.

“Living in this world now where basic health protections are no longer in place is very difficult,” Bryant said. “Obviously, for patients and also for providers who experience a whole lot of moral distress, knowing that you can care for someone yet not be able to because lawyers, legislators, the courts are telling you that you can’t. It’s a really uncomfortable and distressing place to be.”

Gray and Bryant can’t help but think about the patients they’ve cared for recently and consider whether the same options will be available after July 1.

It’s a devastating reality, Gray said, to know she still has the same skills to help patients in an array of situations but her hands will soon be tied by new rules where she will have to turn some people away she could previously care for.

“I think every single patient that we’re able to care for is meaningful and important, and we’re able to help change the trajectory of people’s lives,” Gray said. “I worry about all of those people that didn’t make the exceptions [to the new rules], but still have really important things that are happening in their lives and the lack of compassion for the people that didn’t make these arbitrary exceptions. It’s heartbreaking.”

Despite the more burdensome and taxing legal landscape, those providing reproductive health care remain committed to providing as much access as possible. The patients are the motivation.

“I feel this immense responsibility to get it right and to still be able to provide care for people,” Gray said. “There’s a huge stress and responsibility.”

The post After the fall of Roe, physicians confronted their toughest year working in reproductive health care appeared first on North Carolina Health News.

According to the Centers for Disease Control and Prevention (CDC) updated in 2021, North Carolina has 2,460,352 adults with disabilities.

La entrada Special needs: How the language barrier impacts immigrant families in North Carolina se publicó primero en Enlace Latino NC.

By Jaymie Baxley

North Carolina is in the process of reviewing Medicaid eligibility for more than 2.9 million residents amid the unwinding of a federal mandate that prevented states from kicking people off the rolls during the COVID-19 pandemic.

Known as the continuous coverage requirement, the mandate created by Congress in early 2020 protected Medicaid beneficiaries from losing coverage even if they no longer qualified for the program. It expired in April with the end of the public health emergency, allowing states to disenroll residents for the first time in nearly three years.

Terminations are not set to begin until July in North Carolina, but a top Medicaid official for the Biden administration has noticed a concerning trend among states that are further along in the process.

“What we’re seeing across the country for states that have started to disenroll people is that there are large numbers of terminations,” Daniel Tsai, director of the Center for Medicaid and CHIP Services at the U.S. Centers for Medicare and Medicaid Services, said during a videoconference with North Carolina reporters on June 9.

He said a lot of the people losing coverage was because of “procedural red tape,” rather than being over the income limits that determine eligibility. The issue is compounded by a lack of public awareness, according to Tsai. He said many at-risk enrollees do not know about the unwinding and the effect it could have on their benefits.

“I would anticipate when terminations actually start, then you’re going to start to see a bunch of folks realizing for the first time that this is happening,” he said. “That’s of concern to all of us, and we really want to make sure that people get the word out.”

While the criteria for Medicaid varies from place to place, most states use the federal poverty level as a baseline for eligibility. This means the people at greatest risk of losing coverage should be those with incomes that now exceed the limit for their state, which in North Carolina is $24,860 in annual earnings for a family of three.

Several states are reporting worryingly high rates of terminations for what are essentially paperwork issues. A recent study by KFF, formerly known as Kaiser Family Foundation, found that more than 80 percent of unwinding-related terminations in Arkansas, Florida, Indiana and West Virginia involved residents who “did not complete the enrollment process and may or may not still be eligible for Medicaid.” 

“Millions of Americans’ health insurance and health care coverage is really at risk,” Tsai said. “We are urging every state across the country to do more and to take up many of the strategies we have put out on the table from a federal standpoint that really help make it easier for eligible people to stay covered.”

Resuming renewals 

One strategy the Biden administration is promoting, Tsai said, is automatically renewing coverage for people who continue to qualify for Medicaid. According to North Carolina’s unwinding plan, the state hopes to complete most renewals “without any contact with the beneficiary” using information collected from wage databases and other sources. 

Still, there will be cases where the state does not have all the information needed to confirm a Medicaid recipient’s eligibility and must reach out to the person by mail. If that beneficiary fails to respond within 30 days, their coverage could be terminated. 

“One of the really important messages for people is to not only update their contact information, but return the mail,” Tsai said.

Before the pandemic, Medicaid participants typically underwent annual or semiannual reviews to verify that they continued to qualify for coverage. But people who were added to the rolls while the federal mandate was in place have never gone through that process. Statewide enrollment grew 36 percent during the pandemic, with over 797,000 people newly qualifying for coverage from March 2020 until April of this year.

“What we find is a lot of people have no idea that Medicaid renewals have started,” Tsai said. “Consumers were told for three years, ‘Don’t worry, your Medicaid coverage is protected.’ 

“All of a sudden federal law has changed. A renewal form comes but the average consumer doesn’t know what Congress has done and doesn’t even know they need to respond to something.”

In a statement to NC Health News, the N.C. Department of Health and Human Services said 300,000 people are expected to lose coverage over the next 12 months. The agency says it is working to “ensure people eligible for Medicaid do not lose coverage and those no longer eligible are transitioned smoothly to affordable health plans.”

For some North Carolinians, that may mean going through the federal health insurance marketplace.

People ordinarily have only 60 days to enroll in a marketplace plan after losing Medicaid, but CMS has created a special enrollment period for individuals affected by the unwinding. They can apply for marketplace coverage at any time through June 31, 2024.

Expansion overlap

The timing of the unwinding presents a unique challenge for North Carolina, which is set to become the 40th state to expand access to Medicaid. 

Medicaid expansion was signed into law by Gov. Roy Cooper mere days before the continuous coverage mandate expired. It is expected to benefit hundreds of thousands of North Carolinians with incomes that are less than 138 percent of the federal poverty level for their family size — $34,306 for a family of three — up from the state’s previous limit of 100 percent.

DHHS has confirmed that many residents who lose coverage during the unwinding will become eligible again once expansion officially goes into effect, likely this summer. That won’t happen until a state budget is approved, which still could be months away.

“When you start renewals with expansion still to come and you’ve got a gap, it just leads to people having a gap in coverage and some confusion and resource challenges,” Tsai said. “Hopefully folks will have every chance in North Carolina to, if they’re eligible for Medicaid expansion when that starts, be able to seamlessly transition into that.

“And of course, if they’re not eligible for Medicaid, we want to make sure they’re getting over to other forms of coverage.”

The post As NC begins Medicaid ‘unwinding,’ federal official warns of worrying trends appeared first on North Carolina Health News.

By Will Atwater

On Friday, three large chemical manufacturers agreed to contribute $1.19 billion to a fund to settle lawsuits brought by water utilities across the country that allege that the companies contaminated drinking water supplies with per- and polyfluorinated chemicals, or PFAS.

This announcement comes as lawsuits — filed by state governments, environmental advocacy groups, water utilities and others — accusing Chemours, DuPont and Corteva of poisoning the environment and causing illness among people with long-term exposure to PFAS are piling up.

Seven years after the Wilmington Star-News first published the announcement about the presence of GenX compounds in Cape Fear River deposited there by DuPont spinoff Chemours, the settlement agreement was met with skepticism by many in the environmental community.

“I am extremely concerned about this, as lawyers are going to make a ton of money off the backs of contaminated communities — and giant chemical corporations are getting out easy,” said Dana Sargent, executive director of Cape Fear River Watch, a Wilmington-based environmental advocacy group.

Cape Fear River Watch sued Chemours in 2018 for discharging the chemical GenX into the Cape Fear River. The action led to a consent order among Cape Fear River Watch, Chemours and the North Carolina Department of Environmental Quality.

The order required Chemours, among other things, to develop and execute a PFAS remediation plan for contaminated air, soil and water for the affected lower Cape Fear River Basin communities. 

This area includes New Hanover, Brunswick, Columbus and Pender counties. Like many critics, Sargent believes the pledged funds represent a small fraction of what’s required to address the nationwide problem.

“This settlement comes nowhere near the amount needed to cover the devastation they have caused. It is clear they’re coming out on top; their stocks have gone up as their shareholders see this as their liability issues being behind them,” Sargent said. “I am grateful that, to my knowledge, lower Cape Fear utilities are not participating in this settlement.”

Since the 1940s, PFAS — referred to as “forever chemicals” for their persistence in the environment and the human body — have been used in the manufacturing of oil and water-resistant products, as well as products that resist heat and reduce friction. 

More than 12,000 PFAS compounds are almost ubiquitous in nonstick cookware, cosmetics, cleaning products, dental floss, water-resistant clothing and textiles, and in some firefighting foams and firefighting turnout gear.

While there is no definitive evidence about PFAS posing health risks to humans, there is mounting research that suggests links between extended exposure to forever chemicals and weaker antibody responses against infections in adults and children, elevated cholesterol levels, decreased infant and fetal growth, and kidney and testicular cancer in adults.

Who’s eligible?

Settlement funds are only available to municipal water systems with detectable levels of PFAS and systems required to monitor for PFAS per “EPA monitoring rules or other applicable laws,” according to the news release. 

Water systems not eligible include those managed by state and federal governments and small systems that currently have no PFAS detected and are not required to be monitored. Also, water utilities in the Cape Fear River Basin are ineligible unless they request to opt in, the release says.

In response to the recently announced settlement, the Cape Fear Public Utility Authority, which would be allowed to opt in based on the guidelines outlined in the agreement, posted a response on its website that states, in part:

“Unfortunately, CFPUA has not been provided with the terms of the agreement and we do not know what compensation CFPUA should expect if it were to participate. Our utility’s financial losses and future financial commitments to address our upstream neighbor’s pollution are substantial, and any settlement must substantially address these damages. 

“Litigation will continue until the polluter provides solutions that meet our community needs. CFPUA must consider the best interests of the Authority and the community it serves.”

In 2019, CFPUA, which provides drinking water to more than 200,000 customers in the Wilmington area, started construction on a $43 million granular activated carbon filtration system at its Sweeney Water Treatment Plant to remove GenX and other PFAS compounds from the drinking water supply. 

CFPUA anticipates spending “$3.7 million for Fiscal Year 2023 [and] $5 million in subsequent years,” according to the utility’s 2022 annual report. 

The millions of dollars spent by CFPUA and the ongoing financial burden required to maintain the system are examples of why critics argue that the settlement amount falls short of what’s needed.

“Chemours, DuPont and Corteva’s recent $1.19 billion agreement will not cover the installation of reverse osmosis filters to all 101 water providers in North Carolina, let alone the over 150,000 public water systems in the U.S.,” said Beth Kline-Markesino, founder of North Carolina Stop GenX in Our Water, a grassroots advocacy organization based in Wilmington. 

A closer look at the agreement

The following are key points outlined in the agreement, according to the release:

• Chemours will contribute 50 percent (about $592 million), DuPont about $400 million and Corteva about $193 million. The court ordered the money to be deposited in a fund and made available within 10 business days of being approved by the court.

• If the agreement is finalized in 2023, a final ruling will be delivered by the U.S. District Court for the District of South Carolina. Then, those wishing to join the settlement will have a certain amount of time to do so. If not enough water systems join the settlement, the chemical companies can decide to opt out of the agreement. 

• If an agreement can’t be reached with plaintiffs, the chemical companies have vowed to defend themselves in court against pending litigation.

Though many environmental advocates argue that the best way to address the issue of PFAS contamination is for manufacturers to stop producing the chemicals, there was a sliver of optimism coming from the North Carolina Attorney General’s office after first hearing about the settlement agreement. Attorney General Josh Stein has filed several lawsuits against Chemours.

“Our office is pleased to see Chemours/DuPont/Corteva beginning to take some responsibility for their actions,” said Laura Brewer, Stein’s communications director. 

“We look forward to reviewing the details of the proposed settlement. Based on initial reports, this proposed settlement does not address all of the issues in A.G. Stein’s lawsuit,” she said. “A.G. Stein’s case against these companies continues, and he will continue his work to ensure that the water North Carolinians drink is clean and safe.”

The post Critics skeptical as chemical companies agree to $1.19 billion PFAS settlement appeared first on North Carolina Health News.

Tres mujeres mexicanas que trabajaban con visa H-2A como cocineras en un campamento agrícola llegaron a un acuerdo monetario con su empleador tras sufrir graves abusos.

La entrada Empresa deberá pagar más de $100,000 a trabajadoras con visa por trata de personas y robo de salarios se publicó primero en Enlace Latino NC.

By Trista Talton

Coastal Review Online

State-by-state emergency plans aimed at minimizing the impacts of natural disasters overwhelmingly understate extreme heat as a hazard to human health, according to a Duke University analysis.

The recently released policy brief, “Defining Extreme Heat as a Hazard: A Review of Current State Hazard Mitigation Plans,” highlights the need for states to better evaluate the growing threat of extreme heat as the climate changes, identify populations of people most vulnerable to high temperatures, and implement plans to educate and assist those populations.

Ashley Ward, a senior policy associate with Duke’s Nicholas Institute for Energy, Environment and Sustainability and co-author of the brief, said the report is not a critique, but rather a guide to help states’ emergency management departments better incorporate extreme heat in their hazard mitigation plans.

“We want to give them some easy-to-pick-up roadmaps about how they can do so,” Ward said in a telephone interview. “Our hope is to make their job easier and to supplement what’s already happening at FEMA. We want to be of assistance. That’s what we’re trying to do here.”

Not planning for heat

The Federal Emergency Management Agency recently announced states must incorporate climate change into their hazard mitigation plans, a move Ward called a “really big deal” in part because it prioritizes extreme heat as a hazard.

Extreme heat is when daytime temperatures rise above 95 degrees and nighttime temperatures do not dip below 75 degrees.

Unlike natural disasters such as hurricanes or tornadoes, extreme heat is not a Stafford Act hazard.

The 1988 Robert T. Stafford Disaster Relief and Emergency Act, which amended the Disaster Relief Act of 1974, authorizes the president to declare disasters and provide financial assistance to state and local governments.

The law mandates states update their hazard mitigation plans every five years. Many states are in the process of renewing their plans, Ward said.

So, the report focuses on current states’ plans, half of which lack a dedicated section to extreme heat, the analysis found. 

Ward and co-author Jordan Clark, a postdoctoral associate for the institute’s Water Policy Program, used a scoring system created by the National Resources Defense Council, or NRDC, to assess each states’ plan.

The NRDC used the scoring system to look at the incorporation of extreme heat in southeastern states’ hazard mitigation plans.

“As we know, this is certainly a pressing problem in the southeast, but we know the southeast isn’t the only region in which heat is a problem,” Ward said.

Heat, she said, is one of the most misunderstood weather events.

Ten years ago, researchers in her field focused on something called the urban heat island effect, which is created when natural landscapes are replaced with pavement, buildings and other surfaces that absorb and retain heat.

This effect is very important and very real, Ward said, but its sole focus is on urban areas, leaving out whole populations impacted by extreme heat.

“In North Carolina, heat illness rates are about seven to 10 times higher in rural areas than they are in urban areas,” she said. “And, in fact, what we’re seeing in the small amount of research that’s coming out of the southern part of the United States is that’s not a North Carolina phenomenon. A recent study came out of Florida that showed the same thing. There’s a lot of reasons this is the case, but that just gives you one example of how broadly heat has been misunderstood.”

Where N.C. stands

North Carolina has an enhanced hazard mitigation plan, also referred to as the 322 Plan, which includes natural hazards as well as man-made, technological and human-caused hazards.

The plan addresses different populations identified by the North Carolina Department of Health and Human Services, which narrows down the largest group of people who suffer heat injuries as men between the ages of 18-34 either involved in athletics or outdoor work such as farming and construction.

The plan was updated last year and approved by FEMA in February. The current plan expires February 12, 2028, according to Chris Crew, North Carolina Emergency Management mitigation plans manager.

Crew explained in an email responding to questions that the plan’s definition of extreme heat is taken from the U.S. Centers for Disease Control and National Weather Service, which identify extreme heat as hotter and/or more humid than average summertime temperatures and unusually hot and humid weather lasting at least two days.

The first recommendation offered in the report is for states to establish their own, specific standard definition of extreme heat.

“That is because extreme heat in North Carolina is not the same as extreme heat in Oregon and it’s important that people think about their geography with respect to how we define extreme heat,” Ward said.

That and other recommendations are intended to provide education and awareness about the complexities of heat, she said, how things like how extreme heat correlates to effects on human health.

Take temperature metrics. Heat index, a metric that combines air temperature and humidity, is a common metric decision makers use to define extreme heat, but it is less robust in determining potential adverse health outcomes than a metric known as wet bulb globe temperature.

Wet bulb globe temperature, or WBGT, measures heat stress in direct sunlight and includes temperature, humidity, wind speed, sun angle and cloud cover. This standard metric is used by the military and high school athletic associations, Ward said.

“And that’s important because if you’re sweating outside and it’s very humid there’s a lot of moisture in the air so your body is not evaporating that sweat off of your skin,” she said. “However, if it’s windy outside then the wind is drying the sweat off your skin and that mimics that evaporative cooling process and actually provides a protective factor for you.”

Therefore, in coastal counties especially, it’s important to think about wind speed, Ward said.

Building resilience

North Carolina’s Sandhills region has the highest rate of heat-related illnesses in the state. Roughly 75 percent of those who go to emergency departments for treatment are men between the ages of 15 to 45, Ward said.

Counties within that region, including Bladen, Hoke, Robeson, Sampson and Scotland counties, are included in a heat-health alert system through the N.C. Building Resilience Against Climate Effects program.

This CDC-funded program is tailored to vulnerable populations, including low-income and elderly communities, farmworkers, and youth in sports, according to the state’s plan.

“The State’s position is ‘Extreme’ heat is more of an individual and regional value than a specific value for everyone across North Carolina,” Crew said in an email. “Setting a statewide definition of extreme (heat) would limit the State into responding to a single type of weather scenario statewide when the State health agencies need the flexibility to respond to different weather conditions in different regions to the State.”

Ward praised North Carolina’s emergency management department, calling it a “gold star in the nation.”

While the state does include an assessment for heat hazard, it could better incorporate socially or medically vulnerable populations and teach residents how to protect themselves from extreme heat, she said.

Some ways to cool off after being exposed to extreme heat include taking a cool shower then sitting in front of a fan or placing your feet in cool water.

North Carolina’s plan notes the North Carolina Climate Science Report, which projects that much of the Piedmont and coastal plain will experience a jump in very hot days by 10 to 20 days per year between 2021 and 2040 as compared to the 1996-2015 average.

The number of warm nights in those regions is projected to increase anywhere from three to 15 nights a year. Some areas within those regions could see an increase by 18 or more nights a year.

The post States greatly underestimate extreme heat hazards: Study appeared first on North Carolina Health News.