Nine months after Monroe County Hospital in rural South Alabama closed its labor and delivery department in October 2023, Grove Hill Memorial Hospital in neighboring Clarke County also stopped delivering babies.

Both hospitals are located in an agricultural swath of the state that’s home to most of its poorest counties. Many residents of the region don’t even have a nearby emergency department.

Stacey Gilchrist is a nurse and administrator who’s spent her 40-year career in Thomasville, a small town about 20 minutes north of Grove Hill. Thomasville’s hospital over financial difficulties. Thomasville Regional hadn’t had a labor and delivery unit for years, but women in labor still showed up at its ER when they knew they wouldn’t make it to the nearest delivering hospital.

“We had several close calls where people could not make it even to Grove Hill when they were delivering there,” Gilchrist told Stateline shortly after the Thomasville hospital closed. She recalled how Thomasville nurses worked to save the lives of a mother and baby who’d delivered early in their ER, as staff waited for neonatal specialists to arrive by ambulance from a distant delivering hospital.

“It would give you chills to see what all they had to do. They had to get inventive,” she said, but the mother and baby survived.

Now many families must drive to reach the nearest birthing hospital.

Nationwide, most rural hospitals no longer offer obstetric services. Since the end of 2020, more than 100 rural hospitals have stopped delivering babies, according to from the Center for Healthcare Quality & Payment Reform, a national policy center focused on solving health care issues through overhauling insurance payments. Fewer than 1,000 rural hospitals nationwide still have labor and delivery services.

Across the nation, two rural labor and delivery departments shut their doors every month on average, said Harold Miller, the center’s president and CEO.

“It’s the perfect storm,” Miller told Stateline. “The number of births are going down, everything is more expensive in rural areas, health insurance plans don’t cover the cost of births, and hospitals don’t have the resources to offset those losses because they’re losing money on other services, too.”

Staffing shortages, low Medicaid reimbursement payments and declining birth rates have contributed to the closures. Some states have responded by , by allowing the , or by encouraging urban-based obstetricians to open .

Yet the losses continue. Thirty-six states have lost at least one rural labor and delivery unit since the end of 2020, according to the report. Sixteen have lost three or more. Indiana has lost 12, accounting for a third of its rural hospital labor and delivery units.

In rural counties the loss of hospital-based obstetric care is associated with , studies have found. The share of women also increases in rural counties that lose hospital obstetric services.

And researchers have seen an — when a baby is born three or more weeks early — following rural labor and delivery closures. Babies born too early have higher rates of .

Births are expensive

The decline in hospital-based maternity care has been decades in the making.

Traditionally, hospitals lose money on obstetrics. It costs more to maintain a labor and delivery department than a hospital gets paid by insurance to deliver a baby. This is especially true for rural hospitals, which see fewer births and therefore less revenue than urban areas.

“It is expensive and complicated for any hospital to have labor and delivery because it’s a 24/7 service,” said Miller.

A labor and delivery unit must always have certain staff available or on call, including a physician who can perform cesarean sections, nurses with obstetric training, and an anesthetist for C-sections and labor pain management.

“There’s a minimum fixed cost you incur [as a hospital] to have all of that, regardless of how many births there are,” Miller said.

In most cases, insurers don’t pay hospitals to maintain that standby capacity; they’re paid per birth. Hospitals cover their losses on obstetrics with revenue they get from more lucrative services.

For a larger urban hospital with thousands of births a year, the fixed costs might be manageable. For smaller rural hospitals, they’re much harder to justify. Some have had to jettison their obstetric services just to keep the doors open.

“You can’t subsidize a losing service when you don’t have profit coming in from other services,” Miller said.

And staffing is a persistent problem.

Harrison County Hospital in Corydon, Indiana, a small town on the border with Kentucky, in March after hospital leaders said they were unable to recruit an obstetric provider. It was the only delivering hospital in the county, averaging about 400 births a year.

And most providers , a particular problem in rural regions that might have just one or two physicians trained in obstetrics. In many rural areas, family physicians with obstetrical training fill the role of both obstetricians and general practitioners.

Ripple effects

Even before Harrison County Hospital suspended its obstetrical services, some patients were already driving more than 30 minutes for care, the Indiana Capital Chronicle . The closure means the drive could be 50 minutes to reach a hospital with a labor and delivery department, or to see providers for prenatal visits.

Longer drive times can be risky, resulting in more scheduled inductions and C-sections because families are scared to risk going into labor naturally and then facing a harrowing hourlong drive to the hospital.

Having fewer labor and delivery units could further burden ambulance services .

And hospitals often serve as a hub for other maternity-related services that help keep mothers and babies healthy.

“Other things we’ve seen in rural counties that have hospital-based OB care is that you’re more likely to have other supportive things, like maternal mental health support, postpartum groups, lactation support, access to doula care and midwifery services,” said Katy Kozhimannil, a professor at the University of Minnesota School of Public Health, whose research focuses in part on maternal health policy with a focus on rural communities.

State action

Medicaid, the state-federal public insurance for people with low incomes, pays for nearly half of all births in rural areas nationwide. And women who live in are more likely to be covered by Medicaid than women in metro areas.

Experts say one way to save rural labor and delivery in many places would be to bump up Medicaid payments.

As congressional Republicans debate President Donald Trump’s tax and spending plan, they’re considering to help pay for the bill’s tax cuts. Maternity services aren’t on the chopping block.

But if Congress reduces federal funding for some portions of Medicaid, states — and hospitals — will have to figure out how to offset that loss. The ripple effects could translate into less money for rural hospitals overall, meaning some may no longer be able to afford labor and delivery services.

“Cuts to Medicaid are going to be felt disproportionately in rural areas where Medicaid makes up a higher proportion of labor and delivery and for services in general,” Kozhimannil said. “It is a hugely important payer at rural hospitals, and for birth in particular.”

And though private insurers often pay more than Medicaid for birth services, Miller believes states shouldn’t let companies off the hook.

“The data shows that in many cases, commercial insurance plans operating in a state are not paying adequately for labor and delivery,” Miller said. “Hospitals will tell you it’s not just Medicaid; it’s also commercial insurance.”

He’d like to see state insurance regulators pressure private insurance to pay more. More than 40% of births in rural communities are covered by private insurance.

Yet there’s no one magic bullet that will fix every rural hospital’s bottom line, Miller said: “For every hospital I’ve talked to, it’s been a different set of circumstances.”

is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Stateline maintains editorial independence. Contact Editor Scott S. Greenberger for questions: info@stateline.org.

But time is tight. Compelled to get through all of the day’s appointments, doctors and nurse practitioners have about 20 minutes to check the physical side of things, but in the rush, questions often go unasked and unanswered.

That’s where (CHWs) come in. The job varies, and so does the title, but broadly, a CHW is a trusted connector and advocate who supports well-being in their community. Some work for a health care system or clinic, while others work for a school or nonprofit organization. The tools of their trade are cultural competency, a willingness to listen and a knack for building strong relationships.

A by a group at the calls for the integration of CHWs in early childhood well-child care. According to the report, these workers “often live in the community they serve, bringing unique and valuable skills to address health disparities. Their roles include providing culturally appropriate health education, coaching, social support, and direct services, as well as care coordination, case management, and care navigation, among others.” The authors also highlight that “community health worker” is an umbrella term that includes a range of roles including “health advocates, patient navigators, health coaches, and in Spanish ‘promotoras’ or ‘promotores de salud.’” 

The report shows that an increasing number of hospitals and practices are integrating these workers into well-child care, highlighting evidence that this practice supports young children and families in low-income communities and sharing action steps for pushing this practice forward.

“If we don’t use this opportunity, then we’re going to pay later,” says the report’s lead author Dr. Tumaini Rucker Coker, chief of general pediatrics and professor of pediatrics at the University of Washington School of Medicine and Seattle Children’s. She points to a growing body of evidence on the value of community health workers. Coker worked on one , for example, that demonstrated the effectiveness for improving the receipt of preventive care services for families.

Another study she led, involving , points to greater participation in well-child appointments and reduced emergency room visits — which translates into cost savings. 

“Families need to talk with someone about the challenges that they’re facing in parenting,” says Coker. “They might need advice on doing that hard work of parenting. They might need emotional support, but they don’t always want to tell their primary care provider all the struggles that they have, other than ‘My kid has a rash or cold, those kinds of things.’”

“We tend to look busy,” she admits.

Community health workers offer support on many other issues that come up related to areas including parenting, eating, sleeping and cognitive development. They can identify developmental delays to help ensure that young children arrive in kindergarten ready to learn. They can connect families to services such as supportive housing. It depends, she says, on the character and capacity of the community.

The CHW role in the 1990s and was related to the treatment of children with asthma, as medical providers realized that having someone evaluate environmental factors in the home could help manage the condition. The COVID-19 pandemic the part community health workers play in keeping families healthy, as they expanded bandwidth to support families as medical offices and hospitals were stretched to capacity. As Coker recalls, “It was like, Wow, families really need this. The needs really outstripped the capacity that clinics had.” 

There’s an ecosystem of national and local organizations and networks focused on community health workers. The , for example, integrates into pediatric primary care teams. These specialists are highly trained and are expected to be conversant in professional practice guidelines, regulations, and laws; to possess a basic vocabulary in medical terminology and relevant diagnoses; and to know about health screens, medical procedures, and referral processes. Meanwhile a  in New Haven, Connecticut combines birth doula training with community health worker instruction.

While training is key for these professionals, Coker contends that the effectiveness of CHWs is not necessarily tied to a specific degree, license or certificate, making the role even more cost-effective than originally envisioned. “If we require a level of training and education that’s too high,” she says, “then it becomes impractical for many communities. It’s not about a license. It’s about that ability to connect with people in the community in a way that builds trust.” 

With — a model that fosters collaboration across medical practitioners and community partners — she says, the goal is for “everyone to be working to the top of their ability and the top of their training.” 

Even if a community health program is low cost and ultimately saves money for the family and the nation, it’s still an investment. Community health workers are paid through a range of funding mechanisms, and these days, Medicaid — — is . 

Coker explains that while CHWs are increasingly funded through Medicaid, multiple states have amendments that should cover the work even in the event of diminished federal dollars. She says the current situation might compel policymakers to say, “Hey, let’s be more efficient with the use of our primary care providers, our nurse practitioners, our docs who are more highly specialized than a community health worker.”

Medicaid, she says, has been instrumental in supporting team-based care and community health workers, adding, “And I just hope we don’t go backwards on that.” 

The $10.5 million the state provided to help people pay for job training and industry certifications ran out approximately six months ahead of schedule.

Legislators added an additional $7.5 million worth of grants to the last week during a budget hearing. The initial $10.5 million for the program was supposed to last through June but ran out in December, .

Named for former Gov. Mike Foster, the grants provide financial support for students looking to earn credentials in high-demand, skilled industries such as construction, health care and information technology.

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The money can be put toward programs at Louisiana’s community and technical colleges and the state Board of Regents has approved. Students can generally receive $3,200 per academic year or $1,600 per semester if they are enrolled full time. The award maxes out at $6,400 in total over three years.

People who qualify must come from households earning less than 300% of the federal poverty level, which is $43,740 for a single person or $90,000 for a family of four. They also cannot have previously earned an undergraduate degree, and the students must also be at least 20 years old to qualify for the current academic year.

The types of job training the grant covers include nursing degrees, masonry, roofing, plumbing, cloud computing and .

The extra $7.5 million being used to fund the programs is unspent money from 2023, the first year the grants were awarded. Not as many people took advantage of the program that year because it was new and not well known at the time, officials said.

Monty Sullivan, head of Louisiana’s Community and Technical College System, said he believed the surge in interest in the program is related to economic factors, such as the rising cost of groceries. People are seeking ways to make more money, he said.

“The program is working. That’s the bottom line,” he said.

The Louisiana Board of Regents has asked that state lawmakers double the funding available for M.J. Foster grants to $21 million for the next academic year.

is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Louisiana Illuminator maintains editorial independence. Contact Editor Greg LaRose for questions: info@lailluminator.com.

In mid-April, nurses in Wichita, Kansas, ratified their first-ever union contracts with two Ascension health system hospitals. The victory followed a similar win in March in Austin, Texas, when nurses at Ascension Seton Medical Center voted to ratify their first union contract with Ascension. Neither success came easily or quickly, say members of (NNU), the country’s largest union and professional association of registered nurses.

“I don’t think [Ascension] calculated on our determination and resolve to get the results we wanted, and our patients needed,” says Marvin Ruckle, NNU member and a veteran nurse who has worked at Ascension St. Joseph in Wichita since 1989, with 24 of those years in the Neonatal Intensive Care Unit. “Our community has been so supportive, coming out to our strikes, bringing us food and water. Workers from all the other unions around the Wichita area — steel workers, UPS, Spirit (airplane factory) — joined us. Most of these people have either been a patient or had family in one of our facilities and they know there needs to be change.

“This (contract) is an incredible step forward for nurses, so we can work with the hospital to make patient care better for our community,” Ruckle says. “But it shouldn’t have taken this long. We were determined, we kept pushing, and all Ascension did was drag out the process.”

One of the nurses’ most significant wins was safe staffing ratios enforceable through a nurse-led Professional Practice Committee. In Austin, hundreds of nurses spent more than a year in contract negotiations and organizing efforts, participating in two strikes to focus attention on their demands including guaranteed lower nurse-to-patient staffing ratios. At all three facilities, Ascension management responded to the nearly 2,000 nurses’ historic one-day joint strike on June 27 with a three-day lockout.

Mission-Driven Ascension

Based in St. Louis, Missouri, Ascension is one of the largest health systems in the U.S., boasting 140 hospitals and 40 senior living facilities in 18 states and the District of Columbia. Becker’s Hospital Review listed Ascension as No. 2 in its 2019 list of 100 of the largest hospitals and health systems in the U.S. and the largest nonprofit health system by hospital count. The nonprofit Catholic health system’s stated mission is to deliver “compassionate, personalized care to all, with special attention to persons living in poverty, and those most vulnerable.”

A deeply researched analysis from the National Nurses Organizing Committee and NNU, “,” questions how closely Ascension hews to that mission, particularly in communities with high poverty rates and a disproportionate number of Black and Latino residents. Ascension, the report states, is one of the nation’s worst offenders in closing obstetrics units and obstetrics services. Over the past decade, Ascension has eliminated obstetrics services at 16 hospitals and slashed more than a quarter of the labor and delivery departments that it had been providing in 2012, a rate three times higher than the national average of 6 percent.

Since 2022 alone, Ascension has closed five maternity wards, all health care markets where Ascension maintains a monopoly or near-monopoly on health services. Half of the hospitals where Ascension closed labor and delivery units are in counties with a higher proportion of low-income residents and people of color, and higher rates of infant mortality than the national average (also known as “persons living in poverty, and those most vulnerable” — see Mission Statement above).

Profits over Patients?

By now, the statistics are familiar to anyone paying attention: the U.S. has the highest rate of death among pregnant women and infants of any wealthy country; maternal mortality is more than 10 times and infant mortality almost double the average among comparably wealthy nations. It is no longer even a nasty secret that Black women are nearly three times as likely to die in childbirth as white women.

As “Dangerous Descent” points out, for the first time in two decades, infant mortality has risen in the U.S., largely due to pregnancy-related complications, which experts attribute to limited access to specialists who deal with complicated pregnancies. According to the Centers for Disease Control and Prevention, more than of pregnancy-related deaths in the U.S. are preventable — and healthcare leaders have a major role to play in improving these outcomes. Tragically, many systems focus their eye most keenly on the fiscal bottom line rather than the fundamental health of their patients.

Hospital consolidation has been on the march over the last two decades, with more than 67 percent of U.S. hospitals now belonging to a larger system, compared to 45 percent in 2000. NNU’s report cites numerous studies that have shown that such highly consolidated markets can lead to price increases and diminished patient outcomes. Hospital corporations say such consolidation creates “efficiencies” that enable them to cut costs. What they don’t say as loudly is that steps such as eliminating and obstetrics services — both major casualties of hospital cost-cutting — also improves their profits. In practice, consolidating labor and delivery limits access to care for many patients in low-income areas who may not have vehicles or good access to public transportation. Increased distance to medical care can result in missed prenatal appointments or an inability of patients to get to the hospital in time to deliver their babies safely.

According to the , more than 400 maternity services closed in the U.S. between 2006 and 2020. Between March and June 2022, 11 health systems announced they were closing their obstetrics services. When birthing units close, obstetricians and nurse-midwives are more likely to go elsewhere, exacerbating the epidemic of maternity care deserts in the world’s largest and most robust economy.

“What was really striking to us,” says Elana Kessler, author of NNU’s “Dangerous Descent” report, “is that this is a mission-driven hospital system under the Catholic church that is to care for the poor and to create a more just society. Their actions are not in line with that mission statement. By closing labor and delivery units in Medicaid-heavy areas with higher proportions of Black and Latino patients, they’re hiding behind their mission while they’re increasing their profits.”

Health reporting news site stated in a 2021 investigation that Ascension, “a wealthy, religious, tax-exempt health system,” had migrated toward behaving like a Wall Street firm, using its wealth to create a sophisticated investment strategy that includes a partnership with the private equity firm, TowerBrook Capital Partners. Ascension stands out from other nonprofit hospitals that have dabbled in private equity investing in the sophistication and expansiveness of its $1 billion partnership with TowerBrook, the STAT investigation found.

On its 2021 federal tax return, Ascension reported that CEO Joseph R. Impicciche received a salary of $13 million. In 2022, the reported that Ascension had spent years reducing its staffing levels to improve profitability even though the chain is a nonprofit organization with nearly $18 billion in cash reserves. At that time, its charity care accounted for 1.9 percent of operating expenses (against a national average of 2.6 percent).

Even with the additional revenue from its investments, Ascension pursued cuts to safety-net hospitals in Washington, D.C., and Milwaukee, Wisconsin, abruptly closing its Labor and Delivery unit in December 2022, leaving Milwaukee’s south side, home to a large immigrant community, completely without a hospital to deliver babies. The move prompted a scorching letter from Wisconsin Sen. Tammy Baldwin, who demanded answers from Ascension on its questionable priorities that funnel cash to its investment funds and executives, putting providers and patients at risk. In her letter, Sen. Baldwin called on Ascension to reinvest its cash reserves in hospitals that serve vulnerable communities and to increase pay and improve working conditions for its “burned out and overextended health care workforce.”

In an April 19 email response to Early Learning Nation magazine, Sen. Baldwin stated that Ascension had replied to her letter. ��“While I’m encouraged that Ascension appears to be taking the communities’ concerns seriously and working to rebuild relationships,” she wrote, “I remain concerned that their business practices appear more like a private equity firm than a nonprofit hospital whose stated mission is to serve the public.”

Understaffed NICUs and Obstetrics Units

“It’s been like working in a MASH unit,” Ruckle said, describing his experience in Ascension St. Joseph’s NICU. Mobile army surgical hospitals (MASH) units, which were phased out in the early 2000s, were known for their primitive conditions, grueling work schedules and frustrating lack of resources. As reported in “Dangerous Descent,” nurses at multiple Ascension hospitals have noted the perpetual crisis caused by staffing cuts and equipment shortages.

“It’s heart-wrenching to go home and wonder if you were able to help that critically ill baby as best you could and worry that they aren’t going to have the best outcome,” he said.

The result for nurses can be not only stress and frustration but, according to Zenei Triunfo-Cortez, one of NNU’s presidents, moral harm.

“As nurses, we have an obligation to advocate for our patients, to do what’s best for our patients,” she says. “But the situation we’re being put in, especially Ascension nurses, is that we know we have to do the right thing and are being prevented from doing so because of the situation in our hospitals. Then we suffer from moral injury. Our hearts are breaking because we want to do what’s best, but our employers are not providing what we need to do so.

“We start asking, ‘Is this really worth my health?’” says Triunfo-Cortez, who has been a registered nurse for 44 years. “The majority of our nurses will be out there fighting for our patients and fighting for what’s right, but it does make us question.”

Recommendations from NNU

Pointing out that Ascension enjoys hundreds of millions of dollars in tax breaks thanks to its nonprofit status yet continues its abandonment of low-income mothers, parents and newborns, NNU and the National Nurses Organizing Committee recommend systemic changes that would align Ascension with its mission:

• Come to the table and listen to nurses; staff every unit to ensure the best care for patients.
• Commit to reopening closed labor and delivery wards.
• Provide obstetric services at all new hospitals Ascension opens or acquires.

Ascension has the opportunity and resources to become an industry leader, says Kessler, the report’s author. “As nurses advocating not only for nurses but for the patients they serve, we know that safe staffing and readily accessible care are completely entwined in the work nurses do — they’re one and the same.

“Ascension will say, ‘Consolidation is part of our business strategy. It’s better for the patient,’ but at the end of the day,” she says, “it doesn’t happen that way. It creates barriers for patients to face — transportation, child care — and when there is not ready access to obstetrics services, pregnant patients are less likely to get prenatal care, which then has a cascade of harmful effects.”

��������Բ����Dz�’s 1 in 50 Report

In late April, Ascension released a in which it reported that one in 50 U.S. babies is now born at an Ascension hospital, no doubt in part to what The Wall Street Journal (WSJ) cited as the corporation’s role as the “most active dealmaker” in its hospitals’ expanding into wealthy areas while shunning poorer ones. Nonprofit hospitals now account for half the $1 trillion U.S. hospital sector. Across the sector, the �³���’s investigation found, though they receive local, state and federal tax breaks in exchange for providing charity and benefiting communities, nonprofits are less generous in providing aid than their nonprofit rivals.

Though the Ascension report states that its commitment is “rooted in the loving ministry of Jesus as healer” and the 32-page report details positive health outcomes throughout the system, NNU’s Kessler says the report doesn’t tell the full story of how those numbers arrived.

“Outcomes for patients no longer served by Ascension wouldn’t be included in the hospital’s data, so the report is incomplete,” she says, “failing to consider the impact on communities where Ascension has shuttered obstetrics services under the corporate strategy of ‘consolidation.’

“Ascension asserts that one in 50 babies are born in their care, which only underscores the importance of Ascension keeping obstetrics services open for the thousands of expectant mothers they serve each year.��Furthermore, a snapshot of data from one year, in one health system, doesn’t tell the whole story of the impact of ��������Բ����Dz�’s decision to close services. It should also be noted t��could weigh the data in favor of showing better than average outcomes.”

In theory, the ACA shouldn’t have affected public school districts all that much. Most already offered health care plans that met the ACA’s requirements to at least cover 10 “,” and a “Cadillac Tax” on high-cost plans that had been included in the original bill was delayed and then eventually . 

Teachers were and remain more likely than other workers to have access to health care benefits. They also are than private-sector professionals to receive ancillary benefits, like coverage for dental, vision and prescription drugs, and continued benefits after retirement.

But at the time ACA passed, school district health care costs were growing rapidly. According to a survey from the Bureau of Labor Statistics called the , the price tag for teacher health insurance benefits was rising at a rate of nearly 6% per year. In contrast, inflation was growing at just over 2% a year.

Observing these patterns in the broader economy, ACA champions talked about “bending the cost curve” and reducing the rate at which health care expenses would grow over time. 

It worked. Within public education, district health care costs immediately began to slow. And, in the last three years, the relationship has flipped entirely, with teacher health care costs growing considerably more slowly than inflation.

It’s not just happening in education. Private-sector employers are seeing similar improvements, as are other government-provided health programs, such as Medicare and Medicaid. 

One explanation for the slower rates of growth for employers might be that they have simply shifted more of the costs onto the backs of employees. Within education, for example, the share of medical care premiums for a typical individual health care plan picked up by employers has from 89% in 2010 to 85% in 2023. The comparable rate for family plans has also dipped, from 69 to 65%. 

In other words, school districts are asking teachers to pick up a slightly higher share of their health care benefits. By my rough calculations, that has cut the average educator’s take-home pay by a little more than $300 per year for those covered by individual plans and almost $900 for those using family plans. 

It’s also possible that the plans themselves have changed and shifted more costs onto workers through higher deductibles and co-pays and other out-of-pocket expenses. That’s hard to prove for teachers specifically, but per-person out-of-pocket expenses have risen by about $175 since 2010, in real terms.

That’s not nothing. But it pales in comparison to the savings on the employer side. According to the bureau’s data mentioned above, districts are saving a little over 9% of each teacher’s salary thanks to the slowdown in health care costs post-ACA. That works out to an average saving of more than $6,000 per teacher, or roughly $25 billion nationwide. 

Of course, districts haven’t passed all those health care savings on to teachers, at least partly because districts have to stretch their budgets over more employees. 

Moreover, while districts may have seen their health care costs slow down, employee benefit costs overall continue to rise, thanks to large increases on the retirement side. As I noted in last summer, teacher pension costs are rising about 8% every year, and they have shown no signs of slowing down. 

In other words, district budget officials have gotten a measure of relief from the slowdown in health care expenses. But the average school employee may not be seeing or enjoying the benefits of these trends.

Babies born to mothers on Medicaid died at almost twice the rate of babies born to mothers with private health insurance.

That may read like an indictment of the federal Medicaid program, but it isn’t. Rather, it’s a reflection of the program’s limitations, the complicated circumstances of mothers experiencing poverty, and sometimes a simple matter of geography.

“Medicaid is fantastic and undoubtedly has improved outcomes for mothers and babies. But even though it’s beneficial, it isn’t as good as private insurance,” says Dr. Colm P. Travers, neonatologist and assistant professor of pediatrics for the University of Alabama at Birmingham School of Medicine. “Babies don’t get to choose who their parents are, how much money their parents make or what they do for a living. The baby shouldn’t suffer because of their parents’ socioeconomic status.”

Travers led a recent study on how insurance status relates to infant outcomes in the U.S. The study, “,” was published in the October 2023 issue of JAMA Network Open. The study used data from the birth and infant death records database of the Centers for Disease Control and Prevention (CDC) from 2017 to 2020. Researchers analyzed data of more than 13 million infants; 54% born to mothers with private insurance and 46% to mothers with Medicaid. The study found that those with private insurance had a significantly lower risk of infant mortality — almost half the rate of mothers with Medicaid — as well as a lower risk of low birth weight, vaginal breech delivery and preterm birth. They were more likely to receive prenatal care in the first trimester compared with those with Medicaid.

Prenatal care is foundational for positive outcomes because the first trimester is such a crucial time for both mother and baby, says the study’s first author, Desalyn Johnson, a soon-to-be MD from the University of Alabama at Birmingham.

“From a biological standpoint for the fetus, that first trimester is when organogenesis occurs,” Johnson says. “The other two trimesters see more growth of the body, but the first trimester is when the heart, the lungs — all the organs — are formed. It’s also a time for recognizing the mother’s baseline risk factors that might put a pregnancy at risk, such as high blood pressure or diabetes. You really want mothers to have access to prenatal care at that critical time.”

Presumed Eligible

Because the prenatal period is so crucial, many states provide presumptive eligibility for low-income mothers, meaning that they can start prenatal care as early as possible in their pregnancy. General guidelines for Medicaid eligibility are set by the federal government, but each state sets up their own requirements for eligibility, which differ from state to state. In states that don’t allow presumptive eligibility, the process for approval can send applicants through an administrative tangle that takes weeks and involves multiple steps to navigate the bureaucracy — at a time when the clock is ticking for both mother and fetus.

“One of the big differences we found in infant outcomes was that the Medicaid population had delayed or inadequate prenatal care, possibly because of the process they have to go through before they can even get an appointment for their first prenatal visit. That can mean by the time they get approved, they’re delayed in their prenatal care, or they haven’t received adequate care in those first months. They’re already behind,” she says.

Sometimes whether an expectant mother can receive adequate care boils down to whether she can get to it, Johnson adds.

“Here in Alabama, a lot of our population is very rural,” she says. “Some must travel great distances to receive healthcare. When you’re trying to access Medicaid services, it adds to the barrier when you have to go to this county clerk or that building to fill out paperwork and then back and forth. It can be difficult.

“A lot of times, researchers look at urban health, which is very important, but we also need to consider this rural aspect, especially in the Southeast.”

Nowhere to Go

Once a pregnant person does get signed up for Medicaid, there is no guarantee that they will be able to find a health professional to care for them or their babies. According to a research letter published in JAMA Network Open, “,” in 2020, the number of general pediatricians in the entire U.S. was 56,800. Only 2,900 of these doctors worked in rural counties; 86 worked in completely rural counties, which the defines as a county with open countryside, fewer than 500 people per square mile and no towns with more than 2,500 population. Nationwide, 1,391 counties had no pediatrician; 1,156 of these were rural counties; 331 counties had neither general pediatricians nor family medicine physicians (FMPs).

The March of Dimes’ 2022 report, “,” finds that about 36% of all U.S. counties have no maternity care, whether obstetric providers, certified nurse midwives, or hospitals or birth centers offering obstetric care — a number that appears to be growing. Maternity care deserts are associated with a lack of adequate prenatal care during pregnancy, treatment of pregnancy complications and an increased risk of maternal death. More than 2.2 million U.S. women of childbearing age 15 to 44 live in maternity care deserts.

Among all highly industrialized countries, the March of Dimes report states, the U.S. is considered one of the most dangerous developed nations in the world in which to give birth.

, counties with neither general pediatricians nor FMPs were more likely to have higher percentage of non-Hispanic Black children, higher child uninsured rates, higher child poverty levels and fewer children enrolled in K-12. The issue of health professional deserts is so pervasive now in the U.S. it even gets its own acronym, HPSA (health professional shortage areas).

This shortage helps explain — though not entirely — why babies, especially post-neonatal intensive care unit (NICU) babies, born under Medicaid don’t receive the same level of postnatal care, such as oxygen monitors and ventilators, as babies born to privately insured mothers. The babies born on Medicaid also face increased risk of dying from trauma, accidents, and — a serious neonatal illness most common in premature babies, especially NICU babies who don’t get human milk.

Lifesaving Alternatives

These negative outcomes don’t have to be assumed for mothers living in poverty, the researchers say. Multiple studies have shown that expanding Medicaid prenatal care can dramatically improve things for both mothers and babies. For example, found that expanding Medicaid to cover prenatal care for undocumented immigrant women in Oregon was associated with more prenatal care visits and improved care, a reduction in the number of babies born with extremely low birth weight, and lower infant mortality rate. Additionally, the mothers’ access to prenatal care was associated with an increased number of well child visits and increased rates of recommended screening and vaccines during the child’s first year.

A study of Medicaid-sponsored provided strong evidence that the program improves the lives and health of mothers and babies. A team of nurses, social workers and other specialists work with the pregnant person’s doctor and local providers to care for mother and child throughout pregnancy and the child’s first year, including a well-regarded . The study found that enrollment in the program significantly reduced the odds of babies dying within their first year.

Ruling Out Race

Aware of important racial disparities in infant outcomes in the U.S., researchers adjusted their health insurance study for race, so the results reflected the difference between mothers on Medicaid and mothers with private insurance, not race-based differences.

“Race is largely a social construct,” Travers says. “Increasingly, medical and genomic studies are showing that there is little basis for race-based medicine in the U.S. In this study, we adjusted for the effect of race in our analysis, not to eliminate race, but to try to take it out of the equation. We purposely looked at insurance and adjusted for race so that we could get at the question of socioeconomic status and insurance specifically.”

For example, a recent from the National Institute of Child Health and Human Development found that newborns of Black patients had the worst perinatal outcomes. But once the study adjusted for insurance status, the difference was no longer significant.

The researchers also adjusted for sex of the newborn, maternal pregnancy risk factors, education level and tobacco use to analyze the differences between the two groups. The difference boiled down to who had the better health care. In other words, infant mortality outcomes are not fully explained by those external factors but are associated with the mother’s socioeconomic status, and access to insurance and adequate health care. Populations that are entirely self-pay, such as undocumented immigrants, may have even poorer outcomes than Medicaid patients —a subject for future study, the researchers say.

The results reflected in these studies don’t point to Medicaid’s failure but to the work remaining to be done to ensure that pregnant women of all socioeconomic circumstances receive the timely, adequate care they and their babies need.

“The draw of pediatrics for us as doctors is that when we’re working with children, we can lay the foundation for them to have healthy and successful lives,” Johnson says. “But if you don’t lay that foundation in the dawn of life, it can have repercussions for their entire lifespan. ��“We’ve now documented that, yes, these findings are what we expected. The next steps now are to decide how we as physicians, as policymakers, can address these issues and improve the outcomes for these babies.”

Further Reading

: In 2020, 42% of all births in the U.S. were covered by Medicaid. About one in nine women of childbearing age (11.6%) in the U.S. was uninsured. About one in 18 children younger than 19 was uninsured.

An interactive map showing which of the states have adopted Medicaid expansion coverage for nearly all adults with incomes up to 138% of the Federal Poverty Level ($20,783 for an individual in 2024) and the 10 states that have not done so.

Here are our top five takeaways:

1. Maternal health care is vanishing. The March of Dimes maternity care deserts as “any county in the United States without a hospital or birth center offering obstetric care and without any obstetric providers.” Its showed that 36% of U.S. counties fit this definition, a 2% increase from the 2020 report.

Areas with low or no access affect up to 6.9 million women and almost 500,000 births nationwide. Of those maternity care deserts, 61% were rural counties.

2. Rural communities are particularly vulnerable. About 2 million rural women of childbearing age live in maternity care deserts at least 25 miles away from a labor and delivery unit, a USA TODAY found. About 1 in 9 rural Native women and 1 in 16 rural Latina women are 40 miles or farther from the nearest maternity ward.

“Half of the nation’s rural hospitals have no obstetric or ob-gyn practitioner,” said Nada Hassanein, health care reporter for . “Research has also found rural, Black communities are more likely to lose their obstetric units.”

Hassanein described the , of a mother who had to drive about 70 miles round trip every other week for her prenatal appointments and to deliver her baby. A long drive or ambulance ride in the face of a life-threatening complication can prove fatal or lead to complications that traumatically change the course of a young life.

3. There are geographic and systemic problems at play. “Rural communities with larger proportions of people of color, such as Jasper, have been found to be farther away from obstetrics than rural white communities,” Hassanein said, adding, “It’s not just a geographical problem, but also a systemic one.”

Our health care system is decentralized and favors volume. For hospitals in these poorer, rural communities, these two factors don’t often offer sustainable support, since they see lower birth volumes and primarily rely on the low rates of Medicaid reimbursements for service.

4. Policies underpin some of today’s ongoing disparities. In Georgia, nearly half of the state’s predominantly Black counties are now considered maternity care deserts.

In researching the state’s health care system, Margo Snipe, national health reporter at , discovered regulations uniquely restrictive in Georgia. “The system makes it super hard to open care, but to shut down a facility, all that’s required is a 30-day notice to the state,” Snipe said.

And existing hospitals or health care systems can fight against the appeal. A woman’s efforts to open a birth center in a Black part of Augusta County are blocked. “She had hundreds of letters of support,” Snipe said, “She still hasn’t been able to open it, because hospitals have fought against it.”

5. Many communities are taking matters into their own hands, like the folks behind the Augusta birth center, and tribal women, who have to travel some of the farthest distances in the nation to receive care.

Hassanein mentioned some who plan on learning to drive an ambulance and others who volunteer as emergency medical technicians. “A hospital closure has a really wide effect on a community, and that has implications for maternal health, but also just general health in an emergency,” Snipe said.

Northwest Arkansas officials hope a new medical school and institute being developed beside Crystal Bridges will solve a host of health care industry problems in a manner that can be replicated.

The Arkansas Legislature’s Joint Committee on Public Health, Welfare and Labor convened Wednesday inside Bentonville’s Crystal Bridges Museum of American Art, which will share its 120-acre campus with two health-focused facilities currently under construction — a nonprofit organization called the Whole Health Institute and its sister organization the Alice L. Walton School of Medicine.

The museum and the two new projects are backed by Walmart heiress Alice Walton, who described herself Wednesday as “the chief cheerleader for transformative health care.” Walton said she has “a close and not symbiotic relationship with health care” as a result of a 12-year chronic condition and multiple surgeries.

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Her latest venture was inspired, in part, by a that showed the region is losing $950 million annually as residents seek medical care elsewhere. That statistic “really got my wheels spinning,” Walton said.

“Arkansas is not a wealthy state,” she said. “We cannot afford to export a billion dollars in medical services elsewhere. Never mind the impact it has on families.”

From the report, Walton said officials developed three pillars towards creating a transformative health care model:

• Training more doctors, and differently, so they focus on keeping people healthy.
• Transforming and realigning the health care payment structure so doctors are rewarded for keeping people healthy.
• Figuring out how to get that $1 billion back into Arkansas.

Walton said she also wants to address the rural health care crisis and believes that can be addressed through increased broadband access that will allow for virtual care that can support the few rural doctors the state does have.

Construction is underway on both the institute and medical school, which are expected to open in 2024 and 2025, respectively. The 154,000 square-foot medical school will integrate the arts, humanities and whole health principles with traditional medical education, officials said.

The school is working through the accreditation process and was recently granted candidate status. Founding Dean and CEO Dr. Sharmila Makhija said the next step is a site visit in about six months. The medical school will then be able to recruit students for the fall of 2025.

The inaugural class will have 48 students, and the school will receive full accreditation once they graduate. Enrollment will likely double at the point, but that will be the maximum amount the school can support, Makhija said.

The creation of the school addresses a recommendation in the 2019 NWA Council report to expand medical education either through growth at the existing University of Arkansas for Medical Sciences Northwest program or the development of an independent medical school.

The report also recommended the addition of 6,000 health care jobs and 200 residency positions.

The Arkansas Legislative Council responded in June 2021 by to support an initiative by UAMS Northwest and Washington Regional Medical Center to establish up to 92 graduate medical positions by 2030. The first residents arrived this summer.

Increasing medical education opportunities could increase in-state health-care providers because students are more likely to work in the communities where they completed their residency, according to a recent study. A found that 57% of individuals who completed residency training from 2011 through 2020 are practicing in the state where they did their residency training.

Arkansas currently has three medical schools — Arkansas College of Osteopathic Medicine in Fort Smith, New York Institute of Technology College of Osteopathic Medicine in Jonesboro and UAMS in Little Rock. UAMS established a regional campus in Fayetteville in 2007.

With regard to realigning the health care payment structure, Walter Harris, Whole Health Institute President and CEO, said it’s currently volume based. Instead, doctors should be incentivized to keep patients healthy.

“It’s not about the number of patients you see, it’s seeing the patients for the right reasons at the right time at the right places…so it’s a different kind of model,” Harris said.

Transforming health care will require a combination of bringing in specialty care and having an institute that can work with the medical school and all local providers, Walton said.

“We want to involve every health care system,” she said. “This isn’t about winners and losers. It’s about how do we connect and make us all better. And so that’s what we’re trying to figure out and what I’ve figured out is it’s not very easy, but I’m stubborn, so we will continue.”

is part of States Newsroom, a network of news bureaus supported by grants and a coalition of donors as a 501c(3) public charity. Arkansas Advocate maintains editorial independence. Contact Editor Sonny Albarado for questions: info@arkansasadvocate.com. Follow Arkansas Advocate on and .

DENTON— A North Texas school district plans to open a new school-based health clinic to serve its students covered by Medicaid, despite concerns from certain parents that the district is overstepping its role.

Leaders in the Denton Independent School District say the clinic will make health care more readily available for its students — 49% of whom are eligible for the federal free or reduced price lunch program, an indicator of economic hardship.

In August, the school board approved a partnership with North Texas nonprofit PediPlace to construct a medical clinic inside one of its high schools. The clinic, which is set to open in January, will be the second of its kind in Denton County, one of the fastest-growing counties in the state.

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PediPlace operates the other clinic in the county out of a high school in the neighboring Lewisville Independent School District. Both clinics provide preventive care, vaccinations and mental health screening and counseling.

Over five million children in Texas are on Medicaid, CHIP or are uninsured, making access to reliable health care difficult and time-consuming. Texas has made over the past several years as the number of uninsured people has decreased. And, the state is still second in child Medicaid and CHIP enrollment.

Because underinsured children struggle to obtain treatment, the gap in care leaves school nurses in a constant battle to support students’ health, says Denton ISD Director of Health Services Nicole Goodman.

“We may be able to get them in to get that one problem solved, but we don’t have somewhere to send them long-term,” Goodman said.

The clinic will be built at Fred Moore High School, an early graduation high school with a small class size of 56 students. All 30,000 students enrolled in the district, regardless of which school they attend will be able to use the clinic as long as they are on Medicaid.

The new clinic opens as. School board meetings addressing the partnership were met with constant public comments from parents concerned about what one parent described as “undermining parental authority.” Multiple parents described the clinic as a “Pandora’s Box” to more clinics in schools or district overreach.

“Grooming and indoctrination of children will more easily happen if you decide to treat children on campus,” Denton resident Mary Knox said during Denton school board’s Aug. 22 meeting.

Critics of the clinic worry students would access care without parental consent, especially mental health services or gender-affirming care. In reality, parents must accompany children in order for them to receive care at PediPlace, and the clinic does not offer any kind of gender-affirming care.

Denton ISD’s board of trustees ultimately approved the creation of the clinic, 6-1. Board member Amy Bundgus was the lone no vote.

While Denton ISD’s clinic was approved, other districts in the state have also experienced the brunt of parents’ rights advocates. The Humble Independent School District in Houston initially halted plans to build a clinic in one of its high schools due to concerns about gender-affirming care and birth control access. It’s moving forward after a 5-2 vote from Humble ISD’s school board.

There are almost 90 school-based health centers in Texas, almost all of them are concentrated in urban areas like Dallas, Fort Worth and Houston. Fewer still are geared solely toward students on Medicaid or CHIP.

The Texas Department of State Health Services funded a small number of school-based clinics across the state until 2021, when state agencies were asked to reduce their budget.

For lower-income family members unable to afford to take days off for doctor visits, school is often their first stop when a child needs to be treated.

“Children would show up early to school to essentially be triaged by the school nurse so their parents could determine, did the child have to go to the doctor?” said Larry Robins, PediPlace’s president and chief executive officer.

In the past decade, the number of health providers who accept Medicaid in Denton County has fallen, from 320 to 183, according to the United Way of Denton County. Dr. Marquis Nuby, a Denton pediatrician who accepts Medicaid, the federal health insurance plan for low income Americans, says finding a doctor who accepts Medicaid can be a daunting task. Many health care professionals in Texas have refused to accept Medicaid because of its .

“There’s kids that will come for my practice that may come from Mesquite, may come from Garland, may come from Wise county, may come from Fort Worth,” Nuby said. “They come out here, because they’re struggling to find a spot.”

And amid a growing national mental health crisis, Nuby said access to mental health treatment is crucial, especially for children.

“Since COVID, it became a tsunami,” Nuby said. “Every time I see someone for mental health, I’m losing money.”

Most school-based health centers are funded by nonprofits or other organizations, like Denton ISD’s partnership with PediPlace. Robins said that despite the “very different communal response” the proposed clinic received compared to PediPlace’s first clinic in Lewisville ISD, he feels community support is stronger than ever.

“I don’t believe that communities would be increasing funding if they weren’t wholeheartedly supportive investors in our mission and in the quality work that we provide,” Robins said.

This article originally appeared in at .

The Texas Tribune is a member-supported, nonpartisan newsroom informing and engaging Texans on state politics and policy. Learn more at texastribune.org.

A coalition of professors from across Idaho have filed a lawsuit in federal court against the state alleging a law prohibiting the use of public funds to promote or counsel in favor of abortion is “sweeping and unclear” and violates their constitutional free speech and due process rights.  

It is the fourth lawsuit filed against Idaho for abortion-related laws, with three others challenging the details of the state’s near-total ban on abortion and a so-called “abortion trafficking” bill that restricts adults from taking minors out of state to obtain abortion care. Tuesday’s lawsuit targets the , which passed in the 2021 session of the Idaho Legislature and prohibited public funds from being used to “procure, counsel in favor, refer to or perform an abortion.” Since public schools are largely funded by the state government, the law applies to faculty and staff at colleges and universities, including the largest schools of Boise State University, the University of Idaho and Idaho State University. Violations of the law include penalties ranging from a misdemeanor to a felony with prison time of up to 14 years, along with termination of employment and restitution of the public funds.

“The NPFAA therefore leaves Idaho’s public university educators with an impossible — and unconstitutional — choice: avoid any speech that could be construed as favorable to abortion in course materials, lectures, class discussions, student assignments and academic scholarship, or risk imprisonment, loss of livelihood and financial ruin for violating the law,” the complaint says.

The lawsuit asks U.S. District Judge David C. Nye to issue a preliminary injunction that would block enforcement of the law.

States Newsroom has reached out to Idaho Attorney General Raúl Labrador’s office for comment.

The Idaho Family Policy Center, a state-based organization that has pushed for anti-abortion legislation since 2020, drafted the bill in conjunction with the Alliance Defending Freedom, a national religious organization that wrote the model legislation used to overturn Roe v. Wade in 2022. Blaine Conzatti, president of the policy center, said in a press release Tuesday that the challenge is “meritless” and he believes it won’t be successful.

“The First and Fourteenth amendments to the U.S. Constitution do not provide carte blanche legal protections for higher education faculty to advocate or engage in criminal behavior on the taxpayer’s dime,” Conzatti said in the release. “The ‘No Public Funds For Abortion Act’ simply does not infringe on academic speech protected by the First Amendment, including classroom discussion on topics related to abortion.”

Professors have significantly altered courses for fear of prosecution, complaint says

The complaint was filed by the , the University of Idaho Faculty Federation and six individual professors: Aleta Quinn, Casey Johnson, Markie McBrayer, Zachary Turpin and Kathryn Blevins of the University of Idaho, and Heather Witt of Boise State University. The national and Idaho chapters of the American Civil Liberties Union are representing the plaintiffs, along with local law firm Strindberg Scholnick Birch Hallam Harstad Thorne.

Scarlet Kim, senior staff attorney with the ACLU Speech, Privacy and Technology Project, told States Newsroom some plaintiffs reached out to the Idaho branch of the ACLU independently and others contacted the union to express their concerns. 

“It’s vital for Idaho’s public universities to have autonomy in fostering vibrant debate on their campuses, free from government interference,” said Leo Morales, executive director of the ACLU of Idaho, in a press release. “Idaho’s abortion censorship law directly undermines that autonomy, attempting to restrict educators’ free speech and stoke fear of retaliation for such speech in our state.”

The complaint states the professors and the faculty within the two union groups teach about abortion across a diverse array of disciplines and say the law has placed a “straitjacket upon the intellectual leaders” of the state’s public universities.

“(The law) has stifled free and open academic inquiry about abortion across Idaho’s public universities,” the complaint states. “Professors who previously taught, discussed or wrote about abortion no longer do so. … The threat of prosecution continues to hang over professors as they plan for the upcoming school year, renewing their dilemma about how to structure their courses, teach their students and pursue their own research.”

A professor of philosophy removed an entire section of her biomedical ethics course that discussed human reproduction out of fear of prosecution, and professors of history, sociology, journalism, political science and social work have significantly altered course content as well, according to the complaint. Professors have also made changes to lectures and halted classroom discussion, stopped assigning, evaluating and giving meaningful feedback on student research and writing, and refrained from pursuing or sharing some scholarly and academic work because of the law, it said.  

Martin Orr, president of the Idaho Federation of Teachers and a sociology professor at Boise State University, said professors have told him they have felt “on edge” during classroom discussions that veer into the topic of reproductive issues and students have reported feeling frustrated by the limitations placed on course content and professor instruction. The lack of clarity around the meaning of the law makes some teachers wonder if even talking about the law is perceived by some as “promoting abortion.”

“This interview might constitute a violation of that law,” Orr told States Newsroom. “For a faculty member, just being accused of a violation could lead to termination, so it’s not like we would necessarily get our day in court before there were severe consequences.”  

Orr said the stress of avoiding legal consequences is a distraction from the work and time that could be given to students, and it can interfere with the types of exercises typically used in a classroom setting. 

“Students are not infrequently assigned to argue a position they don’t agree with, it helps us think critically and communicate more effectively,” Orr said. “Can we suggest, even as devil’s advocate, that students argue in favor of reproductive rights? There are all sorts of fundamental teaching tools that start to look very dangerous in this context.”

Attorneys argue law does not provide adequate definitions

The attorneys also argue the law violates the 14th Amendment of the U.S. Constitution that prohibits vague laws, in part because the law does not provide definitions for words like referring or counseling in favor of abortion. Because the law is unclear, it allows police and prosecutors to arbitrarily and discriminatorily enforce the law and “draw their own lines between permissible and prohibited speech,” according to the complaint. 

In March, portions of an art exhibit  at Lewiston’s Lewis-Clark State College because it included depictions of abortion pills and taped interviews with women who had abortions for various reasons. The college’s spokesperson cited the section of code with the No Public Funds for Abortion Act and said after obtaining legal advice, some of the proposed exhibits could not be included.

At the beginning of the University of Idaho’s fall semester in 2022, the school’s general counsel  to all employees advising them not to provide any reproductive health counseling to students and prohibiting the dispensing of any drugs classified as emergency contraception except in cases of rape. The memo also said the language of the law was unclear and because violations could result in a felony, the attorneys were taking a conservative approach.

Following the memo, Idaho Rep. Bruce Skaug, R-Nampa, introduced a bill in January to withhold sales tax revenue from cities that declined to enforce abortion laws, and that bill included language stating the law should not be interpreted to include classroom discussion of abortion, but it did not advance. The version that  into law, , did not include that language.

The story was originally published at .

The Nevada Legislature has passed a bill that provides long-term substitute teachers who work for 30 or more days .

The state Senate voted 16-4 Tuesday to approve the bill. It passed the Assembly in April by a vote of 31-11. Assembly Republicans Gregory Koenig, Heidi Kasama and Toby Yurek and Senate Republicans Pete Goicoechea, Scott Hammon, Ira Hansen, and Heidi Seevers Gansert voted for the bill.

Assembly Bill 282, if signed by the governor, would allow more than 1,000 educators to buy health care, according to the ACLU of Nevada.

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The state has an and substitute teachers have been used more frequently, at pay capped at $120 per day with no benefits. The $450 stipend is based on the average monthly cost of non-Medicare/Medicaid insurance plans in the state,

“The teacher pipeline shortage has only continued to grow, and substitute teachers have become a lifeline to many of our schools,” said ACLU of Nevada Executive Director Athar Haseebullah in a press release.

The Nevada State Education Association

The Nevada Association of School Superintendents, Washoe County School District (WCSD) and Clark County School District (CCSD) opposed the bill.

“It is absolutely ridiculous that our state’s two largest school districts, CCSD and WCSD, actually opposed a health insurance subsidy for full-time substitute teachers and refuse to provide them with health insurance,” said Haseebullah in a press release on Tuesday.

is part of States Newsroom, a network of news bureaus supported by grants and a coalition of donors as a 501c(3) public charity. Nevada Current maintains editorial independence. Contact Editor Hugh Jackson for questions: info@nevadacurrent.com. Follow Nevada Current on and .

All 80 districts within the Los Angeles County Office of Education’s jurisdiction will have the authority to opt-in to services with Hazel Health, a telehealth provider that has partnered with districts nationwide to connect families with licensed care quickly and at no cost.

Their virtual therapy model removes some key barriers to accessing care from the equation, including insurance coverage, provider shortages or waitlists and transportation. Los Angeles Unified, the nation’s second largest district, and Compton Unified have already opted in.

In , nearly 70% of youth who’ve experienced a major depressive episode did not receive any treatment — 10% above national averages. 

However, the new partnership is not designed to support students long-term.

“Each student can typically expect an intake visit plus six weeks to two months of weekly sessions before being discharged from the Hazel program,” a spokesperson for Hazel Health told ����Ӱ�� by email. “The program is short-term—if your child needs long-term mental health support, we will help identify and connect you with options in your community.”

The $24 million dollar partnership with L.A. Care Health Plan, Health Net, and the L.A. County Department of Mental Health is to address the youth mental health crisis, exacerbated by the pandemic and social media. In addition, , who make up 86% of Los Angeles county schools. 

Los Angeles Unified has not yet finalized their implementation plan. It may take up to twelve weeks before sessions begin, according to a spokesperson from the county’s education office.

In December, some Compton Unified students began to access at-home services, and as of last week, two district schools began offering telehealth visits onsite. By March, the district plans to offer space for students to use at every campus.

Half of mental illnesses start by , and suicide is now the for children. Other school districts already partnered with Hazel include Clark County, Nevada’s largest, and Duval County Public Schools in Florida. 

While a enables youth 12 and up to confidentially sign up and meet with therapists on their own, Los Angeles’s partnership with Hazel will require students to be referred by a parent, guardian or school staff member. 

Over half of Hazel Health’s mental health providers are people of color and over 40% are bilingual. When necessary, clinicians use Language Line to facilitate sessions in students’ preferred language.  

“Hazel Health aligns the hiring of therapists to the demographics of its partner districts,” said Van Nguyen, Public Information Officer for the LA County Office of Education. 

The company launched its first mental health visits in the fall of 2021, which range coping mechanisms and tools for general anxiety disorder, depression, academic stress and bullying. Presently, about 22 clinical mental health positions are vacant.

“Hazel’s hiring practices involve looking for trauma-trained clinicians with deep expertise in children and teens, as well as specific passion areas and specialties (such as LGBTQ). Getting the match right is critical,” Drew Mathias, vice president of marketing, told ����Ӱ��. 

Their clinicians most often use cognitive behavioral therapy, motivational interviewing and dialectical behavior therapy approaches. 

Founded in 2015 by a pediatric emergency room doctor, K-12 educator, and former Apple software engineer, Hazel Health offers physical and mental health care visits to children at over 3,000 public schools.

“It’s hard for parents to know who to trust these days,” says Dr. Nia Heard-Garris, attending physician at the Lurie Children’s Hospital of Chicago. “You google cold symptoms, and it’ll say that you have cancer. It can be hard to distinguish what information sources are legit and whether the sources you find know what they’re talking about.

“First-time parents are often so intimidated,” says Heard-Garris, who was one of the video series’ creators and part of a team of pediatricians, public health specialists, consultants and child development specialists who spent the much of the pandemic lockdown meticulously crafting the content for these seven minutes of reassurance. “Having a baby is a lot to go through. I can’t tell you the number of parents I’ve had in my office crying because they knew they couldn’t do it right.”

In any medical practice, time is of the essence, and in pediatric practice especially there’s a lot to pack in as the clock is ticking. Dr. Carrie Quinn, executive director of the Mount Sinai Parenting Center, says the challenges are twofold:��Providers don’t have enough time in primary care to deliver all the information parents need or want, and providers are trained with a focus on illness and treatment. Questions about parenting and how parenting behaviors can shape a child’s success in relationships and school can affect their mental health, and even physical health and well-being are not always a priority.

“The science is exploding in the area of early childhood development and how the first few years of life are so important in building a strong foundation for the future,” Quinn says.��“As health care professionals, we have an incredible opportunity as we are in front of parents from the moment they become a parent. And we have countless touchpoints with families in the months and years that follow. These are all opportunities for us to support parents, help them be the parent they want to be, and to give their child the best start in life.”

The Sparks video series accomplishes the feat of making certain the family’s medical needs and milestones are met during well-baby visits while also providing the all-important guidance parents seek.

Designed with Parents in Mind

With input the team solicited from experts across the country, the videos blend information on social, emotional and cognitive development with such topics as sleep, safety, nutrition and medical concerns. Parent focus groups guided the creators to design messages in the language and framing that would resonate best. Each video is available in Spanish and English, and the series features an important diversity of families and speakers.

“In selecting the parents to appear in the videos, [we sought] a wide variety,” says Kathy Kinsner, senior manager of parent resources at Zero to Three. “We have same-sex couples, older couples, people who are first-time parents, and a wide range of ethnicities. It’s not a scholarly lecture, but rather, normal parents asking normal things, showing that there’s not just one approach, but many paths to the same parenting goal.”

In accompanying the child’s progress at regular intervals, the videos help shape the mothers’ and fathers’ evolution into parenthood. Few people in our society have much experience with small children when they start their journey with a newborn, Kinsner says. Moms and dads transform in remarkable ways into this being called “a parent,” and the videos foster that process.

“Kids evolve day to day,” she says, “and just when you think you’ve mastered infancy, suddenly you have a toddler on your hands. And that evolution goes on for the next 18 years. So having the videos there, step by step, keeps delivering the message, ‘You can do this. You can do this.’”

The series also provides a welcome alternative to the way pediatric practices once approached advice on parenting. Whatever vestiges of “my way or the highway” might linger from a more hierarchical, paternalistic past are dispelled with Mount Sinai’s approach generally; this series embraces equity and trusts parents to know their own culture and mores.

“Too often in history, families have been told that there is one, defined ‘right way’ of being a parent. We say now that great parenting can look very different from family to family and from culture to culture,” says Rebecca Parlakian, senior director of programs at Zero to Three. “For instance, in the section on dual-language learning, families talk about how they approach introducing two languages to their children — in very different ways. We’ve worked to show that there are lots of healthy, loving approaches — healthy and loving being the secret sauce — to achieving the same goal.”

Just as recent science has demonstrated the powerful impact negative early experiences can have on children’s physical and emotional health, it has also shown that positive parenting can buffer these adverse events. A guiding principle at Mount Sinai Parenting Center is to maximize any opportunity to promote strong parent-child relationships during routine care, to fold coaching and information naturally into every occasion parents have to interact in a pediatric environment. (ELN recently wrote about Mount Sinai’s Parenting Center’s groundbreaking environmental transformation partnership with the Bezos Family Foundation, Vroom and Mind in the Making.) Its first major initiative, , was an online, self-directed curriculum for residents designed to model ways do just that. From an initial pilot with eight pediatric residencies in 2018, the curriculum has flourished to the degree that it is now used by 82 percent of pediatric residency training programs and 18 percent of family medical residency training programs in the U.S.

Building Residents’ Knowledge Base

The video series will also extend the parenting message to pediatric residents, many of whom have never been parents before.

“We see this as a really important tool for educating residents,” Parlakian says. “We intentionally elevated parents’ voices in these videos equivalently to those of the pediatricians’ voices because surveys of parents show that while they trust and appreciate information from professionals, they also put a lot of stock and trust in other parents.

“These parent voices and the tactical strategies we’re offering parents in these videos can spark learning in the residents as well,” she says. “Most pediatricians recognize that it’s essential to build relationships with parents, but sometimes it’s hard to know what to say and how to frame the issues in ways that will resonate with parents.”

User guides offer a set of discussion questions to help residents deepen their understanding and ability to apply the concepts to their work with families, with prompts including, “What struck you in the video? Are you seeing any of these things in your child?” as well as encouraging the residents to talk with the parent about their struggles and achievements.

The video series is flexible to any health care setting and will be offered free to anyone who is interested. Video is a familiar format that doesn’t require a particular literacy level, which makes the information widely accessible. Rather than hand a parent a three-page article on behavioral issues, for example, parents can watch videos of other parents discussing how they approached these challenges.

The user guides for providers offer various scenarios for how clinics can make use of the series. Pediatric practices can make it easy for parents to watch the videos — available via web, text or app — prior to their well-child visits, in the waiting room or while waiting in the exam room before a visit.

Having acquainted themselves with the videos can prepare the providers for any unanswered questions the parents have — or just normalize for them the fact that new parents have a lot of questions, and that any question is a good one.

One of the video series’ key purposes, says Dr. Lisa Satlin, chair of the pediatrics department at Mount Sinai’s Icahn School of Medicine, is to create partnership among the providers and parents, and to provide a real-life education for all parties.

“The ready access of information from professionals and other parents that the series provides promises to build the strong parent-child relationships critical for a��child’s physical, mental and emotional development,” she says.

The series saw a soft launch in the fall and will be widely released and promoted this spring. Dr. Heard-Garris predicts it will be a huge hit for providers, residents and especially for parents. ��

“Never in my years of working at any pediatric institution has there been such extensive guidance for parents on how to navigate these first five years of their child’s life.”

These disparities have rightly led to calls to improve health care to non-English speaking families, from individuals and communities, as well as from the National Institutes of Health and the National Academy of Medicine. However, research undergirds any progress in health care: If it isn’t accurately representing the population, progress is impeded or skewed, and voices are silenced, deepening health care inequity. In this arena, U.S. pediatric research is woefully lacking.

A new review of more than 5,000 pediatric research articles found that only 9 percent included non-English speaking participants. The study, , published in October 2022 in JAMA Pediatrics, screened all original investigation articles published in JAMA Pediatrics, Pediatrics and The Journal of Pediatrics from January 2012 to November 2021. Of the 5,008 articles that met the study’s criteria, only 469 included participants who didn’t speak English. It is one of the first studies to describe the inclusion — or lack thereof — of non-English speaking participants in pediatric research.

According to the study’s senior author, Dr. Maya I. Ragavan of UPMC Children’s Hospital of Pittsburgh, an assistant professor of pediatrics at the University of Pittsburgh, she intended the study to be a call to action.

“The data states a problem,” Ragavan says, “but that’s just the first step in a multi-step process toward equity. It’s only the beginning of addressing health equity. We hypothesized that these numbers would be very low, but you don’t really know until you do the analysis. We wanted to write this paper as a call to action.

“Addressing health equity has to happen in a multi-level way,” she says. “At an individual level, the most important part of this is that it’s the responsibility of researchers and research institutions to make research more equitable to non-English speaking communities. It isn’t the responsibility of the participants to somehow inform themselves better. That’s our responsibility. We need to become trustworthy; we need to do better science. So, at a researcher level, it’s important to start with advocacy and awareness on this topic.”

Ragavan stresses that including non-English speakers in the research doesn’t mean just popping in a few participants who don’t speak English. Researchers need training via conferences, webinars and on-the-ground learning to build a workforce of researchers who know how to do the culturally and linguistically informed work to include non-English speakers, and to train the next generation of researchers.

Change must happen at the institutional level as well, she says. Budgetary constraints are always a barrier, and funding agencies—which, along with academic journals, serve as de facto gatekeepers on what science is viewed as having merit—can make a difference by committing to language equity and supporting that research financially.

Doing the work well is expensive, Ragavan says, and isn’t just a matter of hiring a few translators. Many English words don’t translate into other languages—and vice versa. Being able to move beyond a basic vocabulary into the cultural nuances and experiences of participants is essential to fully hear from them, and fully hearing from them is essential to fully providing the health care they require.

To foster this research, Ragavan says, funders could build in bonuses or supplemental grants for those who are doing the work, and require researchers to specify their plans for including non-English speakers in their studies.

“One of the biggest ways those of us who are involved in this conversation would like to change research is to think about how we can co-create the research with the community,” she says. “Co-creating science with community partners and people with experience ensures that their voices are brought in with the conception of studies. We don’t just want to ask people from the communities to help us recruit participants for the studies, but to bring them in at the beginning of studies and make sure their voices are represented. How can we leverage their experience and make sure we compensate them for their time and their work?”

The Deep Dive

A team of researchers worked together on the study for more than a year, led by University of Pittsburgh medical student Annie Chen, who Ragavan praised for her “amazing job” of organizing the project’s minutiae and coordinating the team. In a rigorous process, the team divided up and read 8,142 articles before winnowing them to the 5,008 studies that met the criteria. Then the researchers combed through those studies to assess how frequently non-English speaking families were included in pediatric research, how rates of inclusion had changed over time, what languages were included, and methodological details about oral and written communication with non-English speaking participants.

With roughly 42 million Spanish speakers in the U.S., it’s unsurprising that Spanish was the most common non-English language found in the research. However, the percentage of people in the U.S. who speak a language other than English or Spanish is increasing, underscoring the necessity of expanding inclusion of other languages. (For example, the U.S. Census reports that 3.5 million U.S. residents speak Cantonese or Mandarin as their first language.)

The result of doing the work to address inclusion and diversity matters not only in deepening researchers’ understanding of the participants they study, but ultimately in providing health care to the entire U.S. population.

The important piece once research becomes more inclusive, Ragavan says, is to sort out how to share that information with the communities involved. We must get the research off the shelves and into the hands of those who want and need it.

“In academia, the standard is the academic paper, which is behind paywalls and not generally accessible. So now, we need to discover how we can thoughtfully share our results back with those communities—through infographics, social media posts or maybe videos.

“It’s important to get the word out,” she says. “Language equity and health equity can’t be an afterthought.”

Groups of retired New York City employees are fighting their own unions over a plan to move them from their current health insurance coverage into a Medicare Advantage plan.

Retirees have filed lawsuits, lobbied the City Council and protested outside the headquarters of the United Federation of Teachers, which represents New York’s public school employees and retirees. They are trying to upend an agreement between the city and its labor unions designed to control rising health insurance costs.

The details are complex, but the gist is that many retired city workers are enrolled in traditional Medicare, which is managed by the federal government and covers about 80% of health care costs. New York City’s administrative code requires the city to cover the remainder for all its retirees and their dependents. The city is responsible for paying the insurance expenses of more than 1.2 million people.

Over the last decade, the costs have begun to drain the city’s health care fund, leading former Mayor Bill de Blasio to negotiate reduction targets with the Municipal Labor Committee, the umbrella group representing the city’s 102 public-sector unions, including the teachers union.

In 2014, the two sides agreed to measures to save $3.4 billion over four years. This was evidently successful, and a successor agreement in 2018 sought to save an additional $1.1 billion over three years. This agreement included the establishment of a Medicare Advantage option.

Medicare Advantage plans are required to provide similar coverage to that of traditional Medicare, but they are administered by private health insurance companies. To draw business, they often offer additional benefits, such as dental and vision care or prescription drug coverage. The main disadvantage is that a retiree can be limited to the insurer’s health care provider network. Currently, almost half of Medicare recipients are covered by Medicare Advantage.

What has some retirees up in arms is that the city’s health care fund “is effectively out of money,” in the Medicare Advantage negotiations. And in the rarest of events, the city, the labor committee, the UFT and the arbitrator all agree that the only way to maintain premium-free health insurance for retirees is to move them into a Medicare Advantage plan.

Retirees who want to stay on traditional Medicare will be able to do so, but they will have to pay a premium, currently computed at $191 a month.

This did not sit well with a significant number of them, who formed the New York City Organization of Public Service Retirees and sued the city. A judge in October 2021, ruling that retirees had not been given enough information.

This prompted the teachers union to issue talking points about the proposal, including “.” The organization responded with “.”

In March, a state Supreme Court justice ruled that , but retirees who chose traditional Medicare couldn’t be required to pay premiums. However, he also said the city was not obligated to provide more than one coverage option for retirees.

This further complicated matters and led to the current showdown. According to the court’s interpretation, the city had the right to force all retirees into Medicare Advantage. To prevent this, the committee wants the City Council to amend the administrative code to allow retirees to keep traditional Medicare (and pay premiums) if they so choose.

That is where the situation stands now, but the retirees group rejects all these arguments. , nor does it want changes to the traditional Medicare coverage retirees have had for years. And it lays the blame firmly at the doorstep of the labor committee and UFT.

“For our former unions and the City of NY to strip benefits away from us, automatically enroll us in a private Medicare plan, violate the contracts that were in place when we left, is a disgrace,” .

Opposition caucuses and dissident members within UFT are lambasting the union for its role in the health insurance proposal.

“At a minimum, the argument for collusion between key union leaders and the city is frankly more realistic than the alternative,” .

Union activist Jonathan Halabi sees collusion among everyone involved. “I have made the case before: [UFT President Michael] Mulgrew, [Municipal Labor Committee President Harry] Nespoli, [District Council 37 Executive Director Henry] Garrido, the whole MLC, [arbitrator] Martin Scheinman, [Mayor Eric] Adams and the city’s financial administration, starting with the [NYC Office of Labor Relations], plus the insurance companies — they are all working in concert. They are colluding. And they leave the evidence all over the place,” .

And longtime UFT retiree and gadfly Norm Scott has been covering all aspects of the controversy, “The Adams/Mulgrew/MLC/OLR/Dracula team have found a flunkie to intro a bill to change the admin code.”

But it isn’t just internal dissidents who are riled up. The Professional Staff Congress, which represents 30,000 faculty and other employees at the City University of New York, is also campaigning hard against the Medicare Advantage plan.

“We believe in the long run, a single-payer health insurance program is necessary, but we also recognize the urgency of the moment and believe that the city must not place the burden of saving $600 million annually on the backs of municipal retirees and their dependents by forcing them into a Medicare Advantage plan or into premiums for opting out,” in a Nov. 7 letter to members.

The City Council vote to change the administrative code, and negotiations with Aetna, the insurance company awarded the Medicare Advantage contract, are supposed to take place this month. But the specter of more lawsuits looms over the entire process.

“We will litigate this as long as I’m breathing. And I’m sure if something happens to me, someone else will be litigating it right behind me,” .

It may be a while before this all gets resolved, and while health insurance costs keep piling up, New York City’s taxpayers are on the hook.

Mike Antonucci’s Union Report appears most Wednesdays; see the full archive.

Here’s what happened. While the hospital’s tiny patients slept, a purposeful crew came through with colorful decals, posters, elevator wraps and other materials, transforming the center into a lively, energized space where simple, evidence-based messages offer tips, guidance and support at every touchpoint a family might encounter as they navigate the space. Though the materials for this environmental transformation are eye-catching, their purpose is far from ornamental: They are a dynamic representation of Mount Sinai’s profound commitment to transforming the delivery of pediatric health care itself.

Though the science couldn’t be clearer regarding the difference positive parenting makes for a child’s health and cognitive, social-emotional well-being, pediatricians often have little formal training in child development. An informal survey of graduating pediatric residents reported that most didn’t feel prepared to advise parents on how to foster this healthy development.

“Pediatricians are often asked behavioral questions,” says Ellen Galinsky, president of the Families and Work Institute, a global authority on early childhood and author of the pioneering book “” “But because they have very little training in child behavior, they may end up giving advice based on what their own parents did — or just not giving it at all.”

“There was an urgent need for them to understand how the child’s mind develops, so in 2012, the Mind in the Making team began collaborating with the (MSPC) to develop a curriculum that would start at the beginning — by training pediatric residents in the science of children’s brain development as well as how to deliver and model this information.”

The resulting curriculum, Keystones of Development, is a free, online program funded by the Bezos Family Foundation that provides residents with evidence-based research on how parenting behaviors influence a child’s cognitive and social-emotional development, and shows how pediatricians can weave information promoting these positive behaviors into routine well-child visits.

From the start, the Parenting Center’s aim with the Keystones of Development curriculum has been to transform the culture of pediatric practice. It’s hard to argue with the program’s success: From an initial pilot with eight pediatric residencies in 2018, the curriculum has flourished to the degree that it is now used by 82 percent of pediatric residency training programs and 18 percent of family medical residency training programs in the U.S.

Top staff at the MSPC wanted to expand the curriculum’s reach even further. What if a pediatric practice could be set up so that every one of its interactions with a caregiver fosters those parent-child bonds and helps parents realize the difference they make in their child’s development? What if every moment the parent is in the clinic or hospital is rich with messages that provide them with the tools and confidence to be great parents?

The idea of turning everyday moments into brain-building opportunities is at the core of Vroom, a program of the Bezos Family Foundation that puts early brain science to work through tips that help parents boost their child’s learning when they spend time together.

To adapt and expand these tips for a health care setting, an interdisciplinary working group was formed to design a to create Vroom messages for strategic placement throughout the hospital, easily visible to caregivers and staff. The working group included Dr. Blair Hammond and Dr. Aliza Pressman, MSPC’s co-founding directors; Dr. Carrie Quinn, executive director; Mariel Benjamin, director of programs and a licensed clinical social worker, all from Mount Sinai Parenting Center. In addition, the working group included Jackie Bezos, co-founder of the Bezos Family Foundation, Megan Wyatt, the foundation’s managing director of early learning, Ellen Galinsky, and a team from Johannes Leonardo, a leading creative agency based in New York City. Key stakeholders and staff, including physicians, vetted and helped create hundreds of messages unique to six of the Center’s units — the prenatal clinic, labor and delivery, the postpartum unit, the neonatal intensive care unit, the general pediatric practice and the pediatric emergency department.

“The transformation at Mount Sinai showed that small moments add up to a big impact. It helped health care professionals and staff to be better brain builders and we hope it will inspire other health care professionals, too,” said Wyatt.

These vibrant messages did, indeed, transform the hospital’s physical environment. A far more powerful aspect of the pilot project, however, has been a comprehensive training program designed to reach any staff member who might interact with parents, caregivers and children in any of the six hospital units. The center created a video introducing the basic science of early childhood development, then trained 1,123 hospital staff members in a one-hour, in-person lab to apply these key concepts. A month after the training, staff received reinforcing modules and monthly newsletters to maintain the momentum.

“The training has been the most exciting part of the project to me,” Hammond says. “The interprofessional groups — nurses, security, business administrators, lactation consultants, housekeeping, physicians and more — all receiving the same training is something that occurs so rarely. And the recognition in a non-hierarchical way of the role we all play in a family’s experience was just amazing. The content we delivered is so positive that at the end of the training session, people were always smiling and saying how great it was.”

“In the training, we talked about how we see our roles in helping parents fall in love with their children,” Hammond says. “How can we have parents recognize the amazing impact they have on their child? How can we in the health care industry discuss, model, praise and invite positive caregiver-child interactions in our everyday health care moments?”

In determining placement of the Vroom health care messages and where families were most likely to encounter staff, the planning team walked through parents’ process from their very first interaction to the moment they received their discharge information and beyond. (As an expression of its teamwork with new parents, the Center offers for parents and caregivers — brief videos on babies’ development from zero to 5 years with practical, actionable advice on babies’ behavior, parenting questions, tips and resources, and essential information on babies’ growth and development.)

Transformation in the Day-to-Day

The result of the environmental transformation is an immersive experience that leaves no stone unturned in making sure the brain-building messages reach the families and then reach them again.

Hammond says she’s one of the lucky ones at Mount Sinai who gets to experience the transformation as a clinician — seeing the sign in the postpartum unit that says, “Parents are born here,” or in the staff offices that says, “Parents matter here.” She says she’s had families in her office take pictures of messages to share with grandparents, had children ask about the pictures and what people are doing (playing peekaboo or Simon says), and see families in the elevator read the signage that says, “Over a million neural connections are made every second in the brain in the first few years of life,” then download the Vroom app.

Designed to Be Copied

The intention of the pilot project was that it be scalable, adaptable and free to pediatric educators and practices everywhere, with training modules and materials designed to be practical and easily replicated. To that end, Dan Torres, Vroom’s senior program manager, is creating a digital starter kit and accompanying training resources that will be available by the end of the summer for interested organizations.

“Mount Sinai did a wonderful job of making the training really accessible in how it can be offered,” Torres says. “It can be in person; it can be virtual. They are experts in the space, and they’ve set it up so that it makes implementation a much easier lift for organizations.”

“Vroom has always been a good, easy fit for home-visiting programs, libraries, child care, Head Start, those kinds of areas,” he says. “Not all children have access to all those things though. If we want to reach as many children as possible, health care settings are where, ideally, children are going to go for well-child visits. This program will be an extra layer that will add a lot of value there.”

For Dr. Sarah Milburn, medical director of the Newborn Nursery at Mount Sinai Kravis Children’s Hospital, one of the program’s greatest accomplishments is the way that it levels the playing field for parents who might never have had any information about childrearing and positive parenting.

“Some families had parents who talked to them, read to them, pointed out things and engaged them in conversation,” she says. “But other parents maybe never have had that demonstrated. Maybe their parents didn’t talk to them, maybe they didn’t grow up around younger children and never saw their parents interacting with a child. Regardless of what was demonstrated for them, we’re demonstrating it now. We’re demonstrating it in what’s on the walls, we’re demonstrating it with how the different staff members interact.

“We may just be in there for a moment, bringing them an ice pack, but we can say, ‘Oh my goodness, the baby has their eyes open. They’re really taking it all in.’ You walk out the door after you’ve handled whatever they needed, but in that split second interaction, you’ve made a difference. And it’s cumulative — all the little conversations they have, all the tips they see everywhere — it all adds up for the family to see how many opportunities they have to interact. They may just be here a few short days, but they’ll take that home with them.”

Milburn says she’s seen the difference in staff as well, in the way they view themselves and how they appreciate their own worth.

“It’s so uplifting,” she says. “Those first few days after you’ve had a baby are so overwhelming and stressful, and having everyone here as part of your team makes such a difference. We always have been part of their team, but I think those interactions when we say, ‘Look what your baby is noticing,’ touch them in a very different way.

“Given what we’ve been dealing with through COVID and everything, it would be easy to feel so worn down from what everyone went through,” Milburn adds. “But spirits are high here and people really appreciate each other.

“This is a really beautiful place to work.”

The Bezos Family Foundation provides financial support to Early Learning Nation.

We met an inspired 15-year-old STEM activist, Kavya Venkatesan, from Old Bridge, New Jersey who believes innovation and STEM can solve social issues affecting everything from bias in healthcare to sustainability. Kavya is also dedicated to building the nation’s female STEM workforce pipeline

She has developed strategies to mitigate the impact of climate change on her home state by creating an app, NJ X Connect, that connects individuals in low-income, coastal communities with flood relief organizations and resources in the event of an emergency. “Because right now, our strategy in those communities should be helping them be more resilient,” she said.

Kavya’s second app, Helios, a heat advisory system, aims to educate users about their risk of being hospitalized from heat strokes.

Her passion for STEM as a means of social change led her to the national organization Society of Women Engineers, where she brings industry professionals and students together to develop solutions for social change.

“I realized diversity, equity and inclusion — it has to be something that we need to focus more on in the STEM field,” Kavya said.

See our full interview — and celebrate our full 2022 class! 

Today we’re spotlighting 14-year-old Steven Hoffen, who attends the Riverdale Country School in the Bronx, New York. 

A pre-pandemic visit to Sindyanna of Galilee, a nonprofit in Israel where Jewish and Arab women work together to foster social change and cultivate hydroponic gardens, inspired Steven to produce a short documentary telling the story of their efforts.

“What really caught my attention was Hadas [Lahav], who was a Jewish [woman] cooperating with Hanaan [Zoabi], who’s an Arab woman,” he said. “And so that really got my interest in all of their projects.”

Steven was especially interested in Sindayanna’s hydroponics, a form of vertical farming that doesn’t require soil or specific climate conditions. As Steven describes it, climate change has caused drier conditions and reduced availability of fertile land in Israel.

Inspired by a David Attenborough nature documentary his family watched on Netflix, Steven produced a documentary, “Growing Peace in the Middle East.” The film was recognized at numerous film festivals and prompted Hoffen to launch a nonprofit, Growing Peace, which is dedicated to using hydroponics “as a medium to educate, empower and help those in need.”

He also raised money to build a hydroponics system for a food bank in Israel that is primarily for Eritrean and Sudanese asylum seekers. 

“[Hadas] said that since my film has been [shown] in different film festivals, 20 more women have joined the hydroponics project,” Steven said. “That really just made me happy.”

See our full interview — and celebrate our full 2022 class!

—Video edited by James Fields and produced by Emmeline Zhao

But the information is critical. A large body of research shows that the more parents know about typical child development and effective parenting, the better they interact with their children and provide them with stimulating environments. Parents with a better understanding of what to expect as their babies develop feel less stressed, more effective, and better about themselves and their infants.

By contrast, parents who don’t know what to expect are often impatient and intolerant of the baby’s actions, misinterpreting normal child development as bratty or malicious behavior, increasing the possibility that the child could be mistreated. Parental impatience and intolerance also directly affect infant attachment, which can lead to harsh, inconsistent, disengaged parenting and the cycle of issues that can arise from that.

Reich, a professor in the School of Education at the University of California-Irvine, researches the factors that influence parenting behavior and how those influences affect children’s development. While working on her doctorate at Vanderbilt University, she and a fellow in developmental pediatrics, Dr. Kim Worley, along with their advisor, Len Bickman, began looking at how the process of delivering parental education might be improved.

In 1994, the American Academy of Pediatrics created the — well-structured, evidence-based parent-education material intended to be delivered across 31 age-based visits. The guidance has been updated and revised over the years, most recently this year, to help health care professionals spread the word on child health and behavior to parents and caregivers. The information is there but getting it into the hands of parents is rarely as simple as it ought to be.

“Theoretically, well-child checkups should be a good time to educate parents about injury prevention, typical development and optimal parenting practice,” Reich says. “But there’s a lot of evidence that if physicians can spend any time covering parent education it tends to be a minute or less, and maybe covering three topics. When parents are interviewed later, even if the physician covered a lot of material, they don’t remember much of it.”

Sometimes the doctor’s office will give parents handouts based on the Bright Futures Guidelines, but often their literacy level is too high for many families. As the two researchers discussed alternative methods of spreading the word, they hit upon the idea of embedding the information in baby books — not books about babies a lá Drs. Spock and Brazelton — but books for babies. The books are written at a first-grade level, have pictures to supplement the text and will be read multiple times.

“If you’ve had a child, you know that you read the same books over and over and over,” Reich says. “We thought we could capitalize on this repetition.”

For the initial Baby Books Project (there are two so far), Reich and her colleagues at Vanderbilt created a three-group randomized study to compare the impact of educational books with noneducational books or no books at all. The researchers created a series of professionally illustrated board books targeted to different stages in babies’ development, with content addressing why babies might be behaving in a particular way, which parents might interpret as misbehavior, and how hitting won’t correct the behavior. The text also discussed tantrums and the value of praise, distraction and redirection when dealing with baby’s meltdown. The noneducational books feature the same illustrations, but without the informational approach. Both sets of books contained images of ethnically diverse families and were written in short, catchy, rhyming stanzas.

The books featured messages on the inside of each cover about self-care for the moms with such topics as managing stress, eating well and what to do when they’re feeling overwhelmed. The first project followed 145 low-income, first-time, predominately African American mothers in the southern US, from their last trimester of pregnancy until their child was 18 months old. In Baby Books 1, all books were delivered in person during home-based data-collecting visits.

Baby Books 2, which Reich developed in partnership with Dr. Natasha Cabrera at the University of Maryland, replicates and expands on the first project by including first-time mothers and fathers, and targeting co-parenting. Families in the study are low- to moderate income in Washington, D.C. and Southern California, and are racially and ethnically mixed. The books were written in both English and Spanish and the project was divided into four parts: families receiving books for mothers, books for fathers, books for both mothers and fathers, and noneducational books.

Thanks to a grant from the National Institutes of Health, the second study, which had been derailed by COVID-19 because researchers could no longer go to subjects’ homes, was expanded to 46 months and the books were mailed to families rather than requiring in-person visits. The results are now being evaluated but early analysis indicates many of the same positive results as Baby Books 1.

Based on assessments at all stages of data collection for Baby Books 1, mothers in the group receiving educational books increased their knowledge of child development and positive parenting practices, showed reduced support for spanking, increased efficacy and read more often to their children.

Children of the mothers receiving the educational books had fewer preventable injuries compared with the other groups. An analysis of medical chart audits of doctor office, emergency room visits and hospitalizations found that the impact of preventing injuries such as burns, cuts, falls and dropping showed that the educational book resulted in an overall estimated cost savings of $14,194 compared to the noneducational book group and $128,954 compared to the no-book group.

“The economist who did the analysis tried to calibrate the cost considering that when a child is injured, they have to be taken to the doctor and the parent has to miss work. There are costs around preventable injuries beyond the injury itself, and if the injury is significant, that can change the family’s quality of life.

“As we were hoping, the families did change some of their safety practices in the home,” Reich says. “If the action was putting away choke hazards or removing plastic bags or keeping dangerous things away from the kids, the moms changed those behaviors — mainly the practices that didn’t cost them money. If it meant installing smoke detectors or using baby gates, we didn’t see any changes because our families were very low income.”

The women’s feelings of stress and depression were measured at regular intervals throughout the project. At baseline — the women’s third trimester of pregnancy — the scores for depression hovered just below the criteria of clinical depression for all the women. Though those symptoms gradually decreased for all in the children’s first 18 months, the intervention group became less depressed faster than women in the comparison and control groups.

Where the needle didn’t move, Reich says, was the mothers’ practices around food. The first books included a lot of information about nutrition and breastfeeding.

“We had zero impact on any of that. The parents did better on demonstrating their knowledge, but they didn’t change their feeding practices whatsoever. That’s a common finding — food practices in families are a really hard thing to change. So, in the second baby books, we took all of that out because it was space in the books that wasn’t having an impact on behavior, so we moved in other information.

“We’ll see how that goes,” she says. “My hope is that with each study we’ll figure out what pieces are really amenable to change, and which aren’t and then really target those that are will have utility.”

Though the books are not available for distribution, the researchers hope that they eventually might be able to partner with a publisher to make the books widely available, for instance in Reach Out & Read programs in pediatric clinics or offered during Women, Infants and Children clinic visits. The books could also be made available through public libraries, preschools or bookstores.

“Maybe it could become like the TOMS shoes model where if someone buys a book, the publisher gives a free book away,” Reich says. “It’s such a low-cost, easy-to-disseminate, easy-to-implement intervention, I would love to see it expand.”  ​​​

She herself moved to the United States from Bangladesh with her family when she was 5, and still remembers the feeling of struggling to communicate with her classmates in the years following. Many non-English speakers, the Quincy, Massachusetts high school junior feared, might miss out on potentially life-saving facts about the virus and immunizations.

“There’s that whole language barrier that makes it a lot more difficult to communicate and share accurate information,” she told ����Ӱ��. “It also does cause a lot of [vaccine] hesitancy.”

Wanting to do her part to combat the problem, the teen in March signed on as a youth leader with the a Boston-based team of high school, undergraduate and medical students of color working to provide information about coronavirus immunizations to the area’s Black and immigrant communities.

Now, she leads online seminars — called “empowerment sessions” — that address some of the most commonly held misconceptions about the COVID shots. The sessions not only provide facts about the vaccine, but also speak to histories of medical racism, such as the infamous Tuskegee study of untreated syphilis where for decades under the guise of free health care. 

Including information on such egregious historical events allows presenters to acknowledge the reasons that undergird many Black, Indigenous, Asian and Hispanic residents’ reservations about the vaccine, said the group’s director of youth programming, Laetitia Pierre-Louis.

“We make sure that we have just these raw conversations about, you know, medical racism and what happened in the past and is still, unfortunately, happening today,” she told ����Ӱ��.

Amid a pandemic that at every turn has taken a disproportionate toll on people of color, killing Black Americans at of white Americans, the We Got Us Project conveys reputable information on the virus to Boston’s most vulnerable communities from voices they can trust, its leaders say.  

It’s the group’s makeup as primarily Black, Hispanic and immigrant youth that helps their message resonate for many residents, said Pierre-Louis, who is also a fourth-year premedical student at Northeastern University.

“I think it’s incredibly important who tells you about the information [on the vaccine],” she said, explaining that her Haitian lineage and ability to speak French have often made her conversations with people of that background easier. 

“Having somebody who speaks with them in their own language, who understands their cultural background … and really understands what they mean when they share out their concerns about the vaccine definitely makes a large difference.”

Especially in discussions with young people, said Habiba, it helps to have a peer deliver facts about the vaccine.

“A lot of times, the things that adults can say to us seem more patronizing … like the way a parent would tell a child to do their chores,” she explained. “Coming from another person your own age, it kind of signifies the importance of it.”

We Got Us — , the first Black woman to serve as student council president at Harvard Medical School — has so far presented to over 400 youth and adults. They’ve run sessions for groups from schools designed to serve immigrant students like the and nonprofits like the . 

The team has also run door-knocking campaigns and held numerous community events. Most recently, in the primarily Black neighborhood of Roxbury, they ran a Nov. 30 session in collaboration with the Boston Children’s Hospital for youth to . 

Through its canvassing efforts, the organization has reached over 2,700 individuals, creating and distributing more than 1,500 mask and sanitizer kits and scheduling , Research Director Melissa Jones, an undergraduate student at Harvard University, told ����Ӱ��. More than half of participants in empowerment sessions said on exit surveys that if the COVID-19 vaccine were offered to them, they would “definitely” take it.

Additionally, the youth-led organization has twice presented to members of the Massachusetts Department of Public Health to inform the agency’s approach to helping marginalized communities access vaccines.

Massachusetts has a higher-than-average overall share of Black, Hispanic and Asian residents immunized against the coronavirus compared to the rest of the U.S., according to published Dec. 2 by the Kaiser Family Foundation. But gaps still remain: The Black vaccination rate (72 percent) lags behind the white rate (81 percent) by nine points, a wider margin than the national average. Numbers published by the state indicate a slightly larger gap.

Though the Massachusetts Department of Public Health does not disaggregate youth vaccination data by race, published in late November by the Massachusetts-based Vaccine Equity Now! Coalition show that communities in the state with higher shares of economically and socially vulnerable households COVID immunization rates among 12- to 17-year olds than locales with fewer vulnerable residents. 

Across the country, racial disparities in youth vaccination worry officials. In five core counties in the San Francisco area, for example, 52 percent of Black students were immunized as of early November, compared to 85 percent of students overall — prompting fears that looming student vaccine mandates imposed by local school districts may have a .

Those disparities underscore, in the eyes of We Got Us members, the pressing nature of their work. Still, when speaking to people who have their doubts about the vaccine, the group’s motto is to “convey, not convince,” Pierre-Louis explained. 

“We want to make sure that [participants] are empowered by the information. We want to make sure that they’re well aware of what’s being discussed about the vaccine so they can make the right decision for themselves,” she said.

Not as a participant but as a youth member, Habiba herself has felt invigorated by what she’s learned. Training to lead sessions for peers, she was introduced to information that school had never taught her, such as disparities in health care and the historical events that explain some residents’ current day distrust of the medical establishment. 

“Once you start to connect those dots, it’s really eye-opening,” said the high schooler, who is considering studying epidemiology in college. 

But every time she logs into a session with the We Got Us Project to promote vaccine equity, Habiba believes she’s working to combat those systemic problems.

“It definitely does feel like one small step,” she said.

Pierre-Louis is similarly gratified. She’s so passionate about her responsibilities with the organization, she said, that it “doesn’t really feel like work” despite having to squeeze in training sessions between her undergraduate courses and studying for the MCAT exam. 

For her, the ultimate purpose of the project is about hearing and elevating the perspectives of marginalized communities amid a life-threatening pandemic. 

It’s how she understands the name itself, We Got Us.

“It really means we’re here for you,” said the college senior. “We’re here to fight for you. We’re going to listen to you. And we’re really here to make sure that your voices are heard.”

Since Sept. 1, the country’s most restrictive ban on abortion has prevented Texans from accessing care if their pregnancy is beyond six weeks. 

Two weeks after the law’s signing, then-high school senior Paxton Smith went viral for swapping her pre-approved valedictorian address to speak out against the legislation in her home state. 

Since giving the speech, Smith says her life has taken a “massive shift.” Now a freshman at the University of Texas at Austin, she balances full-time school with beginning a music career and expanding her activism. 

Smith is leading A War on My Body; A War on My Rights, a featuring contributors across generations, from medical professionals to reproductive rights activists and prominent women’s rights attorneys and . The book’s title references of her valedictory address.   

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Her activist work, it seems, is just beginning. Smith also serves on advisory boards for two nonprofits: , which uses art and storytelling to end abortion stigmas and shame, and the , which helps individuals access safe abortions and contraceptives across the country. And on Sept. 30, she delivered another speech at Power of Women event, ending with a call to action: 

“And if you can’t do it for me, and if you can’t do it for yourself, then do it for every girl who comes after us, every young person who comes after us. Because they are counting on you. So what will you do?”

It’s unclear when Smith and others Texans will regain access to legal abortions. Though a to the conservative Fifth Circuit. The Supreme Court did not delay or prevent the law from taking effect, refusing to act on an emergency appeal made by abortion providers in early September. will likely not pass the Senate. 

President Biden has openly the Texas ban, issuing a statement that it “will significantly impair women’s access to the health care they need, particularly for communities of color and individuals with low incomes.”

Health care providers, lawyers and activists await December 1, when the Supreme Court will hear a Mississippi case challenging the state’s ban on most abortions after 15 weeks. Their decision may upend or solidify Roe v. Wade’s protection of the right to choose prior to “viability,” typically around 24 weeks.

����Ӱ�� spoke with Paxton Smith to get a pulse on how she feels given federal moves and why she’s decided to continue her activism through the collaborative book. 

This conversation has been lightly edited for length and clarity. 

What spurred your personal activism — was it in any way connected to or motivated by your education experiences? 

My personal activism really sparked with the speech. In giving the speech, really what I wanted was for people to understand how it felt, what it really meant for a piece of legislation like this to go into effect and understand that having a pregnancy can have life-changing effects. Nobody else should have the right to make that life-changing decision than me. I am the person that’s going to live that future and I should be the one making those decisions. I wanted people to understand … what it felt like for the decision to be taken out of my hands and put into the hands of a stranger.

I know you’ve mentioned before that your family has often had open conversations on politics and other controversial issues at home even though you sometimes disagree — did you have that openness to talk and explore these issues during the school day as well? 

Sometimes. I think in high school, a lot of times you find a niche group, where they carry a lot of the same perspectives, the same ideas. I didn’t necessarily have the exact same opportunity at school, where people might have had very different opinions than I do. But we definitely did have conversations about politics and things surrounding general human rights.  

Why did you decide to continue your activism through a bigger project? How did you choose a collaborative book, and what impact do you hope that model of storytelling might have? 

One of the things that this book is going to do is try and highlight the different perspectives around abortion that people don’t talk about. It’s going to highlight the racial disparities in being able to access health care. It’s going to address what it’s like being gender queer and being in a situation where you can get pregnant. It’s going to address the LGBTQ+ experience, the experience of being a minor. 

The reason it’s a collaborative book is really to better accomplish that goal, of telling those stories and different perspectives. If I wrote this book alone it would come from an 18- year-old, white, upper middle-class cisgendered girl. It would continue the problem of people’s voices not being listened to, and that’s not what I wanted.

What stories or issues stuck with you after submitting the first draft of the book? 

I can’t really speak to the stories in the book as of right now. But I receive hundreds of messages from people, and a lot of times people share their stories surrounding abortion. Some of the biggest things that stuck with me are the stories of what took place before Roe v. Wade, when abortion was still illegal, and people had to take medical care into their own hands. 

They were getting these back-alley, unsafe abortions and . Thousands of people ended up in emergency rooms. And thousands ended up with severe, life-long injuries. Just hearing these stories — firsthand accounts of people in emergency rooms and doctors saying they are not willing to help because they’re scared of the legal implications, or hearing the stories of people who lost their mothers to unsafe abortions — those really stick with me and motivate what I can try to do.

How did you learn about the and choose it as the place to direct proceeds? 

I actually heard about the Afiya Center at a that was organized by a . Ultimately we chose them because they address the racial disparities in accessing reproductive health care. It’s incredibly important to be able to open up access to more than just white people, because everyone deserves reproductive rights and access to care.

Do you see a future for yourself in education or politics? If not those fields in particular, what are you hoping to do in the future?

I’m actually hoping to become a musical performing artist. I make pop and pop-alternative music. I mostly do it alone. I played trumpet for about eight years and am pretty novice at piano and guitar. My main thing is music production.

Right now, I’m working on putting together a first album. I’m sending out some music to people to see what they think. It’s very much in the early stages but I’m excited to pursue music as a career. That has been my dream since I was a child and I have been so involved with music my entire life. 

Why did you choose to stay in Texas and attend UT Austin?

I chose UT Austin mostly because of the music scene. There’s a lot of music downtown so I’m hoping to do some live gigs once or twice a week. My life has taken a massive shift with the speech and the activism takes up a lot of time. 

What are your songs about? Do you imagine incorporating your activism into your lyrics and songwriting?

I think there’s definitely room to incorporate activism in songwriting. Generally, I write music about what I’m experiencing, thinking and feeling. My life is what runs through the core of all my music, so naturally some of it will be charged with my activism.

I wonder if we could reflect briefly about what’s happening at the federal level. SCOTUS refused to block Texas’s law and the House passed the Women’s Health Protection Act, an attempt to codify the rights established with Roe, though it’s unlikely to pass the Senate. The Department of Justice is also your home state, but that hasn’t reopened access. How are you feeling in light of these moves? How do you hope your peers might push for reproductive rights at this moment?

I’m feeling very hopeful. Really right now there’s a lot of things up in the air and it’s kind of hard to tell where things will land. I’m hoping that my peers continue to do what they’re doing now, which is putting pressure on legislators, bringing attention to the topic and all in all, making it extremely clear that they believe that abortion is a human right. 

A War on My Body; A War on My Rights will be released Jan. 22, 2022, the 49th anniversary of the Roe v. Wade decision, by Di Angelo Publications, a small press in Houston. All proceeds will be donated to , a reproductive justice organization run by and for Black women and girls to transform relationships to sexual and reproductive health. The center educates and provides resources to break down racial inequities, decreasing maternal death and HIV rates. 

For other mothers, though, the feelings of sadness, exhaustion and anxiety run much deeper and can overtake the woman’s ability to care for herself or her family. This deep level of stress has a medical diagnosis — postpartum depression (PPD) — and it is treatable: Medical guidelines recommend counseling and possibly antidepressants for all women experiencing it. Untreated, PPD can have serious consequences for both mother and child and can even spiral into psychosis where the mother may be a danger to herself or her baby.

Medical treatment recommendations don’t matter if women suffering PPD never receive that diagnosis, are not able to access care or are constrained from seeking help by culture and family standards — as is particularly the case for African American and low-income mothers.

About one in seven women in the U.S. develops postpartum depression, or about 15% of American women. For Black women, the risk is much greater, says Dr. Joia Crear-Perry, an OB/GYN who is the founder and president of the , dedicated to eliminating racial disparities in birth outcomes and a co-founder of .

“For Black women, the risk is almost twice that — and that’s just the people we know about,” Crear-Perry says.

For Black women dealing with PPD, seeking help can be particularly fraught with cultural and familial expectations, she says. The Strong Black Woman ethos has served African American women for many generations, describing and affirming the fortitude they’ve needed to prevail in the face of countless challenges. When it comes to childbirth, however, that same strength-based identity can isolate a woman just at the moment she needs the most support, authenticity and connection.

Postpartum depression is not caused by something the mother is doing or failing to do. Though the causes are not entirely clear, the mood disorder likely results from a combination of physical and emotional factors. Chemical changes take place in a woman’s brain after childbirth as hormone levels drop drastically. This chemical seesaw creates mood swings that can set everything in the mother’s life off balance. Fragmented sleep is a major contributor to postpartum depression — from getting up every two hours to feed the baby to chemical changes in the mother that keep her brain so revved up sleep becomes impossible. The result can be an unrelenting exhaustion that feeds on itself and creates a dangerous downward spiral.

“There is a lot of shaming and stigma around mental health,” Crear-Perry says, “and a great deal of stigma about being seen as weak for having to ask for help. We’re supposed to be able to take care of our families, to keep it together and keep marching, right?”

Overcoming that internal and external judgment can feel out of reach to depressed mothers, and even their best intentions can be thwarted by knowing implicitly if not explicitly that as a woman of color, the cards are stacked against her. According to the , women in the U.S. are more likely to die from childbirth or other pregnancy-related complications compared to women in other developed countries. The data show that Black women are three to four times more likely to die from pregnancy-related death than their non-Hispanic white counterparts, and research shows that half of these deaths — primarily from hemorrhage and hypertension — are preventable. Pregnant Black women are to be murdered by their intimate partners than white women. And according to the National Institutes of Health, Black mothers are several times more likely to suffer from PPD but less likely to receive treatment and follow-up.

“To be clear,” says Crear-Perry, “those statistics aren’t because of physiological differences. Being Black isn’t a risk factor for illness, death and depression — being exposed to racial bias is the risk factor.”

According to the , this bias disproportionately affects the quality of care mothers receive during childbirth; research has shown that doctors spend less time with Black patients and the care Black mothers receive is less effective. Providers are less likely to believe Black women’s self-reporting of pain and support their breastfeeding, and more likely to ignore their symptoms and dismiss their complaints. Education, socioeconomic status and even fame offer no protection from the bias Black women encounter, demonstrated by high-profile stories such as tennis superstar health catastrophe and the death of Shalon Irving, an epidemiologist at the Center for Disease Control and Prevention.

The reports that Black women were less likely than white women to initiate mental health care after delivery and more likely to put off seeking treatment longer after the child’s birth. Early detection and treatment can reduce the negative impacts of the illness, but even in that regard, Black women who started treatment were less likely to receive follow-up or continued care compared with white women who initiated treatment. The study reported that Black women generally preferred psychotherapy over taking antidepressants, but for many, getting psychological services can be nearly impossible because states are not required to offer those benefits in their Medicaid plans.

Some African American women suffer in silence because they are afraid of being reported to child protective services if they admit that they are having trouble caring for their children. There’s reason for worry: Numerous studies have shown that child welfare workers are more likely to deem Black mothers unfit to care for their own children and to recommend that the children be removed from their home. According to Child Welfare, two Texas studies found that while Black families on average tended to be assessed with lower risk scores, they were 20% more likely to have their case opened for services, and 77% more likely to have their children removed instead of being provided with family-based safety services.

“So, if you’re worried about someone taking your baby from you and about not being listened to by your doctors and all these other concerns, that makes you even more depressed, right?” says Crear-Perry. “Especially if you’re substance abusing and need help, you worry about trying to get treatment because they’ll take your baby.” Small wonder that fewer than 15% of African American woman with PPD seek professional care.

Altering this complex situation will take nothing less than a transformation of multiple systems in U.S. society — medical, social and political — and a number of non-profits and professional groups are working toward those ends. In the meantime, Crear-Perry says two of the most effective solutions are deeply rooted both in culture and in history: midwives and .

“Childbirth is not a medical phenomenon,” she says. “It has been medicalized, but prior to it becoming white men anesthetizing you and pulling the baby out with forceps, it was indigenous. Even if the role wasn’t called a ‘doula,’ there was someone to care for the mother and support her throughout her pregnancy and birth.

“When I first heard ‘doula,’ it was from a wealthy friend who was pregnant, and I saw it as a thing for rich people. But when you understand what a doula actually provides, doesn’t everybody deserve that support, that person to watch out for them?”

According to , some research shows that one of the greatest triggers for depression is a significant deviation between what a woman expects or plans and what actually happens — whether an unplanned C-section, complications at delivery, a baby with medical issues or difficulties with breastfeeding—particularly with those mothers who do not have support. Supporting the mother through the anticipated and the unforeseen is the work of the doula; caring for mother in a highly individualized way has always been the work of the midwife. Helping the mother get set up for successful breastfeeding is the work of both.

“For Black mothers,” Crear-Perry says, “midwives and doulas aren’t a luxury, they’re the fix.”

That logic seems to have gotten lost lately when it comes to insuring children in the United States. For the first time in nearly a decade the number of uninsured children in the U.S. has increased, despite numerous studies linking coverage of kids to better outcomes for children, families and society.

In some states, it’s the country’s youngest children who are losing coverage fastest, despite the fact that they are the ones who need it most — and for whom it makes the greatest, longest-lasting difference.

Elisabeth Wright Burak, senior fellow at Georgetown University’s McCourt School of Public Policy’s Center for Children and Families (CCF), coauthored a recently released detailing the alarming rise in the number of children under age 6 who have no insurance coverage. For decades, Burak says, the U.S. had experienced a consistent annual decline in the number of uninsured children. Beginning in 2016, that trend reversed and now, loss of health coverage threatens to erase many of the positive coverage gains made until that time.

“Typically, the younger the child, the greater the need for coverage,” Burak says. “The American Academy of Pediatrics recommends at least 15 well-child visits before a child reaches 6, with visits more concentrated in the first two years of life. States have historically had higher eligibility levels for public programs like Medicaid and CHIP (Children’s Health Insurance Program, a federal program for families that earn too much to qualify for Medicaid but not enough to buy private insurance) during these years because it’s been understood that this coverage is so important.”

The multiple interactions with a pediatrician or family doctor provide more than medical coverage, she says. Check-ups can provide a way to check in on family circumstances such as a parent’s depression or financial hardship. Insurance coverage is the first step in making sure children’s health concerns are addressed as early as possible and that the child receives needed vaccinations and other preventative care.

“One of the things our report shows is the connection between parent health coverage and children’s health and coverage,” Burak says. “If a parent has health insurance, they are more likely to have health insurance for their children as well. It makes a difference for parents’ ability to be the best parent they can be because they are getting their health needs met and they don’t have added undue stress over an unpaid medical bill, or an emergency-room visit they can’t afford.”

The importance of continuous health care coverage for children has long-term consequences, Burak stresses.

“Medicaid in particular is associated with better health outcomes for both children and adults,” she says. “It’s also associated with better outcomes such as high school graduation, college graduation and higher earnings as adults. That makes sense if you consider it because, for example, there are conditions and diseases that can be life-altering if they aren’t treated. The earlier you catch them, the better.

“I worked in Arkansas over a decade ago and we would hear stories from families who said things like, ‘I’m so grateful for our ARKids First (Arkansas’ Medicaid and CHIP program) because we couldn’t figure out what was going on with our grandson. When we were able to get tests, we found out he had some serious hearing problems. We got him some help and he was able to start school ready.’

Children experience rapid brain development and social, emotional and physical growth in the early months and years, which means the window for addressing developmental or health challenges is crucial — full of great vulnerability and opportunity. It would stand to reason that governments would want to take advantage of these highly concentrated years to provide society’s children with the best possible start in life.

Beginning in 2016, the precise opposite began to happen in the U.S., with coverage losses widespread throughout the country. Though no state showed a decrease in the rate of young children without coverage, 11 states (Alabama, Florida, Georgia, Illinois, Kentucky, Missouri, Ohio, Tennessee, Texas, Washington and West Virginia) showed a significant increase in the rate and number of uninsured children. Only Minnesota saw a decrease in the number, though not the rate, of children without insurance.

The fact that this rise in the number of uninsured children has occurred at the same time the country is experiencing economic growth and low unemployment is perhaps one of its most incongruent aspects. If rising tides lift all boats, why are our most vulnerable families and children continuing to sink?

A host of national policy decisions have undermined the previous years of progress, Burak says. The efforts in 2017 to repeal the Affordable Care Act, along with a months-long delay in extending CHIP, as well as the Trump administration’s cuts to outreach and enrollment programs designed to help families navigate their coverage options created confusion among parents and caregivers that likely kicked children off public health insurance — namely Medicaid and CHIP — that they remained eligible to receive.

The decision of some states not to expand Medicaid has had a significant impact on the dramatic increase in their numbers of uninsured children. Young children in states that have chosen not to expand Medicaid saw their uninsured rates grow at nearly three times the rate of states that took Medicaid expansion, she says.

Another chilling effect has been the Trump administration’s policies and rhetoric targeting immigrant families, which has deterred many parents from signing up their children — even those who are citizens and eligible — because the parents are afraid of being deported or getting into legal hassles regardless of their status. This unwelcoming attitude is shortsighted at best because what might be a small, relatively inexpensive, treatable problem can become a life-threatening situation that leaves the family no recourse but the emergency room — massively more expensive than an insured, routine visit to a pediatrician or family doctor.

“Traditionally, these insurance programs have been an area where government programs have worked exactly as they were intended to,” Burak says. “Decades of work to provide insurance and improve outcomes though Medicaid and CHIP and then the ACA created a steady decrease in the number of uninsured children in our country. Now that’s reversing.

“The frustrating thing is that, in the world of health insurance coverage, children are by far not the most expensive to insure. If you look at health care spending by those who are receiving health insurance, even just looking at Medicaid, about half of its population is children and they don’t take up nearly half of the spending.”

The upshot to this confluence of discouragement is that more than one million children lost their Medicaid or CHIP coverage in one calendar year from 2017 to 2018 and CCF’s research indicates that things will likely get worse for children before they get better. Given that Medicaid and CHIP enrollment declines came during a time of economic growth, when an economic downturn occurs — and history tells that’s likely — a lot more kids will become uninsured. The numbers will continue to go in a bad direction because the policy reasons behind the decline in coverage will not end with the new year and may accelerate.

“Many states have really done a lot to invest in young kids,” Burak says. “But it’s essential that their leaders know that all the incredible investment in pre-K and early childhood programs is undermined by this trend. These children are not going to be able to thrive in pre-K or anywhere else if we don’t make it easier for families to get their basic health needs met.”

Further Reading

��(Georgetown University’s McCourt School of Public Policy’s Center for Children and Families)

��(Georgetown University’s McCourt School of Public Policy’s Center for Children and Families)

��(Georgetown University’s McCourt School of Public Policy’s Center for Children and Families)

These were the right-time-and-place elements, converging in the spring of 2014, that allowed New York City Mayor Bill de Blasio to reach a relatively little-watched but massive four-year agreement with union leaders to cut health care costs by $3.4 billion. The deal, which must��hit its final savings benchmark in 2018, affects city workers and their families — nearly 1 million people, the city says.

For a workforce that had gone without raises for three years or��longer under Michael Bloomberg, de Blasio’s term-limited predecessor, the package helped the city afford new contracts that included back pay and raises while continuing to spare union members from having to��cover any��of their health insurance premiums. (New York remains the only large American city where this is true.)

“We had an opportunity to completely change the nature of the relationship and to say that we are not here to simply tell you how we have to get these savings,” Robert Linn, the city’s energetic labor relations commissioner, said in an interview. “We’re here to create a process where we work together to do it.”

To de Blasio, New York City achieved the urgent and difficult task faced by government and the private sector everywhere: It “bent the arc”��of health care costs downward, he said.

But budget watchdogs demurred; “some of the largest items have little to do with the current and future behavior and health of city workers,” said George Sweeting, deputy director of the Independent Budget Office, during a February 2016 city council hearing. He cited gains attributed to the agreement that were the result of unrelated trends that slowed insurance cost growth below city projections.

Over the course of the agreement, according to Linn’s office, $1.9 billion of the $3.4 billion in targeted savings, or about 56 percent, will come from lower-than-expected premium costs.

“It’s like taking credit for the sun coming up in the morning,” said Charles Brecher, senior adviser for health policy at the Citizens Budget Commission. The group argued that savings due to “economic trends,” rather than “actual results of specific initiatives,” should benefit all taxpayers. Instead, workers stand to earn bonuses if they exceed the health plan’s savings targets.

Another $200 million over four years will be drawn from dollars the city set aside in a stabilization fund, a reserve it��finances��alone but jointly controls with labor to cover higher costs of some city insurance plans. In the past, the unions would not allow Bloomberg to cut costs by tapping into that money.

The New York state comptroller determined, after accounting for��dollars saved by slower��premium growth and “administrative actions,” that the plan would directly save $544 million, .

Some critics have also complained that the��administration agreed to negotiate practices that should happen anyway as a matter of good government. For instance,��the agreement will��achieve $400 million in savings from auditing insurance rolls for ineligible recipients, such as divorced spouses or adult children; Bloomberg tried to do the same thing, but the unions were able to block him.

Yet��the former mayor’s��difficulty in achieving some of the compromises de Blasio has won suggests that the ability to make even small gains, in a city with a still-powerful labor sector, can’t be taken for granted.

“I’m a little sympathetic to them,” said Brecher’s colleague Maria Doulis, vice president of the Citizens Budget Commission. “They’re establishing a precedent here to say: ‘We’re settling collective bargaining contracts and we’re putting in health insurance into how we think about this.’ It’s my hope that having accomplished that once it becomes part of how collective bargaining is done in New York.”

The city will find out next year: Many of the de Blasio union contracts are expiring this year or in 2018, including agreements with the United Federation of Teachers, DC37, the communications workers, and 1199SEIU, which represents health care workers and is the country’s largest union. The health care agreement, which was negotiated with the Municipal Labor Committee, a coalition of union leaders that represents nearly all New York City workers, ends June 30, 2018.

Barring an act of God, de Blasio will preside over City Hall for a second term, and unlike in 2013, when he wasn’t the labor favorite, unions began endorsing him more than a year before the 2017 election.

‘A historic and sweeping reform’

Mayor Bloomberg was never popular among workers, but he was initially The relationship deteriorated as large raises disappeared following the 2008 recession. By the time de Blasio took office, every municipal labor contract had been expired for at least three years, forcing the new mayor to reach terms with 150 bargaining units representing 300,000 workers impatient and demanding billions in missed and new raises

“This may be the hardest assignment that anyone in the history of labor relations in this city has taken on,” the mayor said when appointing Linn as labor commissioner on New Year’s Eve 2013. Linn had been former mayor Ed Koch’s chief negotiator in the 1980s, built a successful consulting practice, created benefit packages with a hospital union, and negotiated for the Patrolmen’s Benevolent Association, the rank-and-file police union.

He targeted teachers, nurses, and hospital workers, who hadn’t received raises in five years. Just four months into the term, de Blasio announced that Linn had cinched a deal with the powerful UFT, which included an 18 percent wage increase over nine years, retroactive to 2009.

“The Bloomberg administration was willing to let city worker health care costs rise, rather than negotiate meaningfully with the municipal unions,” Michael Mulgrew, president of the 200,000-member teachers union, said in a statement. “But the de Blasio administration has worked with us, and the result is real reductions in what would have been the increase in health care spending.”

The UFT agreement was funded by “a historic and sweeping reform of public employee health care,” City Hall said in the first public mention of a savings agreement, which hadn’t yet been agreed to by the other unions. How these savings would be realized wasn’t explained.

Linn had also been shopping the health savings plan with Harry Nespoli, the Municipal Labor Committee head, who took a shot at Bloomberg. “I heard more worthwhile proposals in the first 45 minutes than I heard the previous three years,” .

Nespoli did not respond to numerous calls for comment.

The commission approved the deal a few days after the UFT announcement, agreeing to meet savings targets of $400 million in fiscal year 2015, $700 million in 2016, $1 billion in 2017, and, in 2018, $1.3 billion. The $1.3 billion would recur annually, Linn explained in a later interview, because it lowered the starting point of ensuing years’ costs.

As a carrot and a stick, unions would receive any surplus up to $365 million above the $3.4 billion, but they were also responsible for delivering each year’s targeted savings even if they were unable to reach them through the agreement’s initiatives.

A labor official said savings were on track to exceed the target, but Linn said he was “not ready” to reach that conclusion.

In June 2014, a month after the agreement was reached, the citizens budget group criticized it as “a collection of one-time or temporary savings.“ A report cited surveys that forecast small growth in insurance premium costs. The city’s much-higher projections were responsibly arrived at “to protect taxpayers from damaging results,” the report said, but “do not reflect the contemporary dynamics of the health insurance market.”

“If insurance premiums decline due to economic trends,” it said, “and not because of any affirmative actions to improve the delivery of health care by the city and the MLC, those savings should be used to offset the expenses of city services, as they always have been, and not to fund raises.”

In April 2015, Linn explained to dubious city council members, who were just then seeing the actual reform measures, that it was on track to meet its $400 million first-year target.

“Many thought this was smoke and mirrors,” . “I think we’ve demonstrated they were absolutely wrong.”

As the watchdogs had feared, however, the city also realized first-year savings of $55 million because the premium costs of HIP HMO, the mostly widely used city plan, increased by 2.89 percent rather than projected 9 percent. Likewise, the premium costs for GHI Senior Care — a Medicare supplement — increased by 0.32 percent rather than 8 percent.

The pushback against counting these as savings created by the agreement was loud enough to move Linn and Dean Fuleihan, New York City’s budget director, to respond in . They said city budget officers had made “prudent” projections based on growth rates over the past 15 years.

The reality of the system

In June 2017, Linn reported expected savings for the remainder of the agreement. Its incentives and price controls, over its last two years especially, appeared to be encouraging better use of medical care. To reduce use of emergency rooms for routine care, for instance, co-pays for visits were tripled from $50 to $150. Programs for managing diabetes and radiology fees were said to have saved millions, as was improved extended care for those with prolonged illnesses or needing rehabilitation.

When it expires in 2018, the agreement will have saved $136 million over four years on specialty drugs, nearly $400 million from discontinuing benefits to those who aren’t eligible, and $135 million by a switch from the HIP HMO plan to the HIP HMO Preferred Plan, according to Linn.

“It is true that we were fortunate that the HIP rate did not go up or the Senior Care rates did not go up as projected,” Linn acknowledged. But, he says, without an “overall structure” that included savings from lower premium increases, the city wouldn’t have been positioned for other savings.

He said he doesn’t think people understood the magnitude of the changes. “Say the MTA has a 2 percent employee contribution to health. [It does.] That would save the city maybe $300 million annually. That is well below the $1.3 billion annual savings that we’ll achieve by the end of the contract,” he said.

“The most important thing was that it helped change the whole relationship between labor and management looking at these problems.”

Some still see the agreement as at best a blown opportunity.

“To present it as a sacrifice on the part of the workers is what’s misleading,” said Bill Hammond, director of health policy at the Empire Center, a right-leaning think tank. “That’s how this was framed to begin with: ‘These are things we traded for at the bargaining table. We gave them raises, they gave us health savings.’

“They should be bargaining for health savings at the table, but they shouldn’t be things the city can do of its own authority. They should be things you need to bargain for.”

The Citizens Budget Commission’s Doulis gives the city credit for getting the union to play along.

“The unions sue over everything, so things that seem like low-hanging fruit, that should have been done 20 years ago, should be done consistently, they sue and they win,” she said. “It blows our minds, but that is just the reality of the system we have here.”

To this way of thinking, those who believe Linn has oversold the agreement may not have accounted sufficiently for the difficulty of collective bargaining in New York City, even if only to change from a plan to a preferred plan or to find out if anyone is getting insurance who shouldn’t be covered.

Health care costs continue to rise, at any rate: about 4 percent annually in the city over the past four years, which Linn compares to about 7 percent nationally. The city comptroller projects 7.4 percent annual growth over the next three years. say they have trouble paying their medical bills, according to the Kaiser Family Foundation.

“When we said we would bend the health care curve, we didn’t say we would turn it negative,” Linn said. “We changed the trend dramatically.”