En las primeras semanas de la pandemia, el doctor Lorenzo González, entonces residente de segundo año de medicina familiar en el Centro Médico Harbor-UCLA, trabajaba hasta 80 horas a la semana en la unidad de terapia intensiva. Siempre tenía miedo de contraer covid-19 y se sentía culpable por no tener tiempo suficiente para ayudar a su padre enfermo.

En abril de 2020, su padre, un jardinero jubilado, murió de insuficiencia cardíaca y pulmonar. González hizo el duelo solo. Su trabajo como médico en formación le exponía a un alto riesgo de contraer el virus, y no quería contagiar a su familia. El estrés económico también se apoderó de él al tener que hacer frente a los elevados costos del entierro.

Ahora, González reclama una mejor remuneración y prestaciones para los residentes que trabajan horarios agotadores en los hospitales públicos del condado de Los Angeles por lo que, según él, reciben menos de $18 la hora, mientras atienden a los pacientes más vulnerables del condado.

“Se están aprovechando de nuestro altruismo”, dijo González. Ahora es jefe de residentes de medicina familiar en Harbor-UCLA y presidente del Comité de Internos y Residentes (CIR), un sindicato nacional que representa a los médicos en prácticas y que forma parte del Sindicato Internacional de Empleados de Servicios (SEIU).

“Necesitamos que se reconozcan los sacrificios que hemos hecho”, señaló.

Los residentes son médicos recién recibidos, que han terminado la carrera de medicina, y deben pasar de tres a siete años de formación en hospitales universitarios antes de poder ejercer de forma independiente.

Bajo la supervisión de un médico profesor, los residentes examinan, diagnostican y tratan a los pacientes. Algunos buscan formación adicional en especialidades médicas como “fellows” (práctica de especialización).

Estos médicos en formación se están agrupando en California, y otros estados, para exigir mayores salarios y mejores beneficios y condiciones de trabajo, luego de la enorme presión vivida durante la pandemia.

Así, se suman a enfermeras y enfermeros, auxiliares de enfermería y otros trabajadores de salud que se están sindicalizando y amenazan con ir a la huelga, ya que la escasez de personal, el aumento del costo de la vida y la falta de uniformidad en el suministro de equipos de protección personal y vacunas contra covid les han llevado al límite.

Más de 1,300 residentes sindicalizados y otros médicos en formación de tres hospitales públicos del condado de Los Angeles, incluido el Harbor-UCLA, votarán el 30 de mayo si se declaran en huelga para pedir un aumento de salarios y de gastos de alojamiento, tras un mes de bloqueo de las negociaciones con el condado.

Desde marzo, los residentes de Stanford Health Care, la Facultad de Medicina Keck de la Universidad del Sur de California y el Centro Médico de la Universidad de Vermont se han sindicado.

“Los residentes siempre han trabajado horarios de locos, pero el estrés de la pandemia les afectó mucho”, explicó John August, director de la Facultad de Relaciones Industriales y Laborales de la Universidad de Cornell.

La Asociación de Escuelas de Medicina de Estados Unidos, un grupo que representa a los hospitales universitarios y a las facultades de medicina, no abordó directamente la tendencia a la sindicalización de los residentes, pero la jefa de atención sanitaria de la organización, la doctora Janis Orlowski, comunicó a través de un vocero que una residencia es un aprendizaje laboral, y que la función principal de un residente es formarse.

Los residentes cobran como aprendices mientras estudian, se forman y trabajan, dijo Orlowski, y la asociación trabaja para garantizar que reciban una formación y un apoyo eficaces.

David Simon, vocero de la Asociación de Hospitales de California, no quiso hacer comentarios. Pero remitió a un estudio publicado en JAMA Network Open, en septiembre, en el que se mostraba que los residentes de cirugía en programas sindicados no reportaban menores tasas de agotamiento que los de los programas no sindicados.

Según el sindicato nacional, hasta el momento ningún nuevo grupo sindical ha alcanzado ningún acuerdo. Pero algunos de los más antiguos han conseguido mejoras en los salarios, las prestaciones y las condiciones de trabajo. El año pasado, un sindicato de residentes de la Universidad de California-Davis consiguió subvenciones para la vivienda y permisos parentales pagos.

Con más de 20,000 miembros, el CIR/SEIU representa a uno de cada siete médicos en formación en Estados Unidos. Su directora ejecutiva, Susan Naranjo, dijo que antes de la pandemia se organizaba un nuevo grupo sindical cada año, y que en el último año y medio se han unido ocho.

Las condiciones de trabajo de los residentes ya habían sido objeto de escrutinio mucho antes de la pandemia.

El salario medio de los residentes en Estados Unidos en 2021 era de $64,000, según MedScape, un sitio web de noticias para médicos, y los residentes pueden trabajar hasta 24 horas en un turno, pero no más de 80 horas a la semana.

Aunque una encuesta cuyos resultados se publicaron el año pasado encontró que el 43% de los residentes se sentían compensados adecuadamente, los que se están sindicalizando dicen que los salarios son demasiado bajos, especialmente teniendo en cuenta la carga de trabajo de los residentes, su deuda de préstamos estudiantiles y el aumento del costo de vida.

La tasa salarial afecta de manera desproporcionada a los residentes de comunidades de bajos ingresos y de color, afirmó González, porque tienen menos ayuda financiera de la familia para subvencionar su educación médica y para pagar otros gastos.

Sin embargo, al tener poco control sobre el lugar en el que se forman —a los graduados de escuelas de medicina se les asigna su residencia mediante un algoritmo—, individualmente, los residentes tienen un poder de negociación limitado con los hospitales.

Para los residentes sindicalizados que buscan ser escuchados, los aumentos salariales y los beneficios, como los estipendios de vivienda, son a menudo la prioridad, dijo Naranjo.

Los pacientes merecen médicos que no estén agotados y preocupados por el estrés financiero, dijo la doctora Shreya Amin, “fellow” de endocrinología en el Centro Médico de la Universidad de Vermont. A Amin le sorprendió que la institución se negara a reconocer al sindicato de residentes, teniendo en cuenta los sacrificios personales que hicieron durante la pandemia.

Si un hospital no reconoce voluntariamente a un sindicato, el CIR puede solicitar que la Junta Nacional de Relaciones Laborales administre una elección. El sindicato nacional lo hizo en abril, y con una mayoría de votos certificada, la sección de Vermont puede ahora comenzar la negociación colectiva, señaló Naranjo.

Annie Mackin, vocera del centro médico, declaró en un correo electrónico que está orgullosa de sus residentes por haber prestado una atención excepcional durante la pandemia y respeta su decisión de afiliarse a un sindicato. Mackin no quiso referirse a las preocupaciones de los residentes sobre las condiciones de trabajo.

La doctora Candice Chen, profesora de políticas de salud en la Universidad George Washington, cree que los Centros de Servicios de Medicare y Medicaid (CMS) también tienen cierta responsabilidad en las condiciones de trabajo de los residentes. Dado que la agencia paga a los hospitales universitarios para que formen a los residentes, debería responsabilizar a los centros de cómo los tratan, dijo.

Y el Consejo de Acreditación para la Educación Médica de Postgrado, que establece las normas laborales y educativas para los programas de residencia, se está moviendo en la dirección correcta con nuevos requisitos como la licencia familiar pagada, agregó, pero necesita hacer más.

Está por verse hasta dónde llegarán estos sindicatos para conseguir sus objetivos.

Las huelgas son poco frecuentes entre los médicos. La última huelga del CIR fue en 1975, la realizaron los residentes de 11 hospitales de Nueva York.

Naranjo aseguró que una huelga sería el último recurso para sus miembros en el condado de Los Angeles, pero culpó al condado de retrasar y cancelar continuamente las sesiones de negociación. Entre sus demandas, el sindicato pide que el condado iguale el aumento salarial concedido a los miembros del SEIU 721, un sindicato que representa a otros empleados del condado, y que se conceda un subsidio de vivienda de $10,000.

Las encuestas realizadas a los miembros del sindicato han revelado que la mayoría de los médicos residentes del condado de Los Angeles dicen trabajar 80 horas a la semana, según Naranjo.

Una vocera del Departamento de Servicios de Salud del condado de Los Angeles, Coral Itzcalli, agradeció a su “heroica” fuerza de trabajo de primera línea por proporcionar “la mejor atención de su clase” y reconoció la importante carga que la pandemia ha supuesto para sus vidas personales y profesionales. Dijo que el Consejo de Acreditación para la Educación Médica de Postgrado establece los límites de horas y que la mayoría de los médicos en formación dicen trabajar “significativamente menos” de 80 horas a la semana.

Jesús Ruiz, vocero de la Oficina Ejecutiva del condado de Los Angeles, que gestiona las negociaciones laborales, indicó por correo electrónico que el condado espera llegar a un “contrato justo y fiscalmente responsable” con el sindicato.

Se espera que los resultados de la votación sobre la huelga se anuncien el 31 de mayo, según comunicó el sindicato.

Esta historia fue producida por KHN, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

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When a listener wrote to us about a pricey colonoscopy quote, we got curious. It turns out, a few years back, investors identified gastroenterology as their next hot-ticket item. 

Private equity companies are the house-flippers of the investment world, and they’ve found their way into many areas of our lives. Now, they’re at gastroenterologists’ offices, too, hoping to change the way these doctors do business and make a quick buck selling the practice down the road. 

In this episode of the podcast, we find out why these doctors are selling their practices to private equity to begin with, and what it could mean for the quality and cost of your health care. 

Here’s a transcript. 

“An Arm and a Leg” is a co-production of KHN and Public Road Productions.

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Emily Pisacreta and Emmarie Huetteman

Mariel needed a new gastroenterologist.

Having just moved back to San Antonio, the 30-something searched for a doctor to manage her Crohn’s disease, an inflammatory bowel condition that is successfully managed with medications and lifelong monitoring — including regular colonoscopies.

Mariel booked an appointment and learned she would be on the hook for a $1,100 colonoscopy — about three times what she had paid for the same test in a different state. Almost three-quarters of the bill would be a “facility fee” for the in-office procedure at a colonoscopy clinic. (KHN agreed not to disclose Mariel’s last name because she is concerned speaking out might affect her doctor’s willingness to manage her medical condition.)

Preventive colonoscopies are covered without patient cost sharing under the Affordable Care Act, but colonoscopies for patients with existing conditions, like Mariel, are not. A 2019 study found patients with inflammatory bowel diseases, including Crohn’s disease, incur about $23,000 in health care costs a year. Medication treatments alone can cost tens of thousands of dollars annually.

But shopping around proved frustrating. Although San Antonio has plenty of gastroenterology offices, more than two dozen of them are controlled by the same private equity-backed group.

In 2018, one of the nation’s largest independent gastroenterology practices, Texas Digestive Disease Consultants, announced a deal with the Chicago-based private equity firm Waud Capital to expand by offering management services to other physicians. At the time, the Dallas-based practice had 110 locations, mostly in Texas — including San Antonio. Today its management group, the GI Alliance, operates in a dozen states with more than 400 locations — and is growing fast.

With market dominance comes the business opportunity to set and maintain high prices. “It’s pretty much the only game in town,” Mariel said.

Private equity, known for making a profit on quick-turnaround investments in struggling businesses across many industries, has taken an increasingly active interest in health care in the past decade. It has invested in gastroenterology practices in recent years to tap into the revenue potential in meeting growing demand.

“We are in the Golden Age of older rectums,” one investment manager wrote in 2017.

Tired of having to manage the increasingly complicated business of running a practice and, often, lured by the sweet deals investors offer, more and more doctors have partnered with or even sold their practices to private equity funds. So investment managers now control the financial decisions for many medical offices caring for patients with digestive ailments. With profit the primary driver, patients may find they pay much more for the same — or less — care.

The Centers for Disease Control and Prevention recently lowered the age at which healthy Americans are urged to begin routine screenings for colon cancer — ensuring that most will undergo regular colonoscopies beginning at age 45. And the population is aging, meaning more people will be needing the procedure.

For those 65 and older, Medicare picks up the tab. But even when a benign polyp is found during a simple screening, patients sometimes end up with an unexpected bill. And less-than-scrupulous providers often find ways to bill for some services, such as out-of-network anesthesia monitoring.

Studies show that private equity investment in health care results in more surprise bills and overall higher costs for patients. Surprise billing is the practice of charging insured patients for out-of-network care unknowingly received, including in emergencies and at otherwise in-network facilities.

Before a federal ban on surprise billing took effect this year, it was common for patients to get slapped with an expensive bill after being treated by an emergency room doctor employed by a private equity-owned staffing service — a problem that policy experts say was not a glitch but rather a business model for private equity companies.

Nearly 10% of the nation’s 14,000 gastroenterologists were partners in or employed by a private-equity backed organization as of last fall, according to a report by Physician Growth Partners, which represents independent physician groups in transactions with private equity.

In 2021, the number of private equity acquisitions of gastroenterology practices grew by 28% over the previous year, according to Spherix Global Insights and Fraser Healthcare.

Complex government regulations, technological innovations, and insurance industry practices have driven many gastroenterologists to sell shares in their practices, said Praveen Suthrum, who runs a consulting company for physician practices. Many physicians argue reimbursement rates are too low to keep up with complex negotiations with insurers and the other rising costs of operating an independent practice.

Private equity typically purchases a stake in a health care practice, then adjusts its operations to make it more profitable. It may switch to cheaper suppliers, shorten appointment windows, bill aggressively, or lay off staff, to name a few strategies — the kind of changes that save money at the expense of patient care.

In December, NBC News reported on how one private equity-owned group of dermatology practices overbooked patients, lost test results, and leaned on cheaper labor from physician assistants and nurse practitioners who may miss critical diagnoses.

A study out last year from the National Bureau of Economic Research showed that when private equity owned a nursing home, patients were more likely to die in their first months there and much more likely to be prescribed antipsychotic drugs — which are known to increase mortality among the elderly. Taxpayer spending per procedure or service in a private equity-owned facility goes up about 11%.

Private equity has shown a lot of interest in health care practices that perform high-volume procedures, especially those with growth potential.

“Lots of people are needing injections in the eye for macular edema, and lots of people need colonoscopies, and lots of people need skin biopsies,” said Dr. Jane Zhu, a health services researcher at Oregon Health and Science University in Portland who has studied the role of private equity in health care. “And these are things that will only grow in volume over time as the population ages.”

Zhu said usually the investors start by acquiring a well-performing practice, or group of practices, in one geographic area — called a “platform practice.”

“It’s well established. It has some brand recognition,” Zhu said. “It has good market reach. There may be multiple sites. It has lots of patients that are already affiliated with that practice, and they buy that up, and there are opportunities for consolidation.”

Mergers create larger groups with more power to negotiate rates with insurance companies and charge what they’d like. The possibility of capitalizing on the good name of a respected practice alone may make it a valuable investment.

Zhu said these medical practices are considered a short- to medium-term investment, with an average period of three to eight years before the investors sell.

Suthrum said private equity firms are good at making their case to doctors, assuring them they’ll let the doctors do the medicine while the businesspeople do the business.

Doctors think, “If I’m going to survive, then I will either have to sell myself to the hospital or, what is the alternative?” Suthrum said in an interview. “The alternative is private equity.”

This article was adapted from a recent episode of “An Arm and a Leg,” a podcast about the cost of health care, produced in partnership with KHN.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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In the early weeks of the pandemic, Dr. Lorenzo González, then a second-year resident of family medicine at Harbor-UCLA Medical Center, ran on fumes, working as many as 80 hours a week in the ICU. He was constantly petrified that he would catch the covid-19 virus and guilt-ridden for not having enough time to help his ailing father.

In April 2020, his father, a retired landscaper, died of heart and lung failure. González mourned alone. His job as a doctor-in-training put him at high risk of catching the virus, and he didn’t want to inadvertently spread it to his family. Financial stress also set in as he confronted steep burial costs.

Now, González is calling for better pay and benefits for residents who work grueling schedules at Los Angeles County’s public hospitals for what he said amounts to less than $18 an hour — while caring for the county’s most vulnerable patients.

“They’re preying on our altruism,” González said of the hospitals. He is now chief resident of family medicine at Harbor-UCLA and president of the Committee of Interns and Residents, a national union that represents physician trainees and that is part of the Service Employees International Union.

“We need acknowledgment of the sacrifices we’ve made,” he said.

Residents are newly minted physicians who have finished medical school and must spend three to seven years training at established teaching hospitals before they can practice independently. Under the supervision of a teaching physician, residents examine, diagnose, and treat patients. Some seek additional training in medical specialties as “fellows.”

These trainees are banding together in California and other states to demand higher wages and better benefits and working conditions amid intensifying burnout during the pandemic. They join nurses, nursing assistants, and other health care workers who are unionizing and threatening to strike as staffing shortages, the rising cost of living, and inconsistent supplies of personal protective equipment and covid vaccines have pushed them to the brink.

More than 1,300 unionized residents and other trainees at three L.A. County public hospitals, including Harbor-UCLA, will vote May 30 on whether to strike for a bump in their salaries and housing stipends, after a monthslong negotiation deadlock with the county. Since March, residents at Stanford Health Care, Keck School of Medicine at the University of Southern California, and the University of Vermont Medical Center have unionized.

“Residents were always working crazy hours, then the stress of the pandemic hit them really hard,” said John August, a director at Cornell University’s School of Industrial and Labor Relations.

The Association of American Medical Colleges, a group that represents teaching hospitals and medical schools, did not address the unionization trend among residents directly, but the organization’s chief health care officer, Dr. Janis Orlowski, said through a spokesperson that a residency is a working apprenticeship and that a resident’s primary role is to be trained.

Residents are paid as trainees while they are studying, training, and working, Orlowski said, and the association works to ensure that they receive effective training and support.

David Simon, a spokesperson for the California Hospital Association, declined to comment. But he forwarded a study published in JAMA Network Open in September showing that surgery residents in unionized programs did not report lower rates of burnout than those in nonunionized programs.

So far, none of the new chapters have negotiated their first contracts, the national union said. But some of the longer-standing ones have won improvements in pay, benefits, and working conditions. Last year, a resident union at the University of California-Davis secured housing subsidies and paid parental leave through its first contract.

With more than 20,000 members, CIR represents about 1 in 7 physician trainees in the U.S. Executive Director Susan Naranjo said that before the pandemic one new chapter organized each year and that eight have joined in the past year and a half.

Residents’ working conditions had come under scrutiny long before the pandemic.

The average resident salary in the U.S. in 2021 was $64,000, according to Medscape, a physician news site, and residents can work up to 24 hours in a shift but no more than 80 hours per week. Although one survey whose results were released last year found that 43% of residents felt they were adequately compensated, those who are unionizing say wages are too low, especially given residents’ workload, their student loan debt, and the rising cost of living.

The pay rate disproportionately affects residents from low-income communities and communities of color, González said, because they have less financial assistance from family to subsidize their medical education and to pay for other costs.

But with little control over where they train — medical school graduates are matched to their residency by an algorithm — individual residents have limited negotiating power with hospitals.

For unionizing residents seeking a seat at the table, wage increases and benefits like housing stipends are often at the top of their lists, Naranjo said.

Patients deserve doctors who aren’t exhausted and preoccupied by financial stress, said Dr. Shreya Amin, an endocrinology fellow at the University of Vermont Medical Center. She was surprised when the institution declined to recognize the residents’ union, she said, considering the personal sacrifices they had made to provide care during the pandemic.

If a hospital does not voluntarily recognize a union, CIR can request that the National Labor Relations Board administer an election. The national union did so in April, and with a certified majority vote, the Vermont chapter can now begin collective bargaining, Naranjo said.

Annie Mackin, a spokesperson for the medical center, said in an email that it is proud of its residents for delivering exceptional care throughout the pandemic and respects their decision to join a union. Mackin declined to address residents’ workplace concerns.

Dr. Candice Chen, an associate professor of health policy at George Washington University, believes that the federal Centers for Medicare & Medicaid Services also bears some responsibility for residents’ working conditions. Because the agency pays teaching hospitals to train residents, it should hold the facilities accountable for how they treat them, she said. And the Accreditation Council for Graduate Medical Education, which sets work and educational standards for residency programs, is moving in the right direction with new requirements like paid family leave, she added, but needs to do more.

How far these unions will go to achieve their goals is an open question.

Strikes are rare among doctors. The last CIR strike was in 1975, by residents at 11 hospitals in New York.

Naranjo said a strike would be the last resort for its L.A. County members but blamed the county for continuously delaying and canceling bargaining sessions. Among its demands, the union is calling for the county to match the wage increase granted to members of SEIU 721, a union that represents other county employees, and for a $10,000 housing allowance.

The union’s member surveys have found that most L.A. County residents report working 80 hours a week, Naranjo said.

A spokesperson for L.A. County’s Department of Health Services, Coral Itzcalli, thanked its “heroic” front-line workforce for providing “best-in-class care” and acknowledged the significant toll that the pandemic has taken on their personal and professional lives. She said limits on hours are set by the Accreditation Council for Graduate Medical Education and that most trainees report working “significantly less” than 80 hours a week.

Jesus Ruiz, a spokesperson for the L.A. County Chief Executive Office, which manages labor negotiations for the county, said via email that the county hopes to reach a “fair and fiscally responsible contract” with the union.

Results of the strike vote are expected to be announced May 31, the union said.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

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This week’s mass shooting of elementary schoolers in Texas (just 10 days after a racially motivated mass shooting at a Buffalo, New York, grocery store) has reignited the gun debate in Washington, D.C., and around the country. But the political disagreements over guns and their appropriate role in American society are as insoluble as ever.

Meanwhile, Oklahoma becomes the first state to try to ban all abortions, as the nation awaits the Supreme Court’s ruling in a case it is expected to use to overturn the landmark Roe v. Wade decision.

And on Capitol Hill, lawmakers criticize the FDA for its handling of the infant formula shortage, rekindling a debate over whether food should be regulated by a separate agency.

This week’s panelists are Julie Rovner of KHN, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, Anna Edney of Bloomberg News, and Rachana Pradhan of KHN.

Among the takeaways from this week’s episode:

• Although much of the nation has been riveted by the May 24 shooting in Uvalde, Texas, thousands of Americans are killed each year in gun violence that doesn’t make headlines. More than half of those deaths are suicides and many others result from isolated shootings.
• Despite an epidemic of gun violence, the regulation of guns in the U.S. has declined in the past couple of decades. Not only did the federal assault weapons ban expire, but many states have moved to make guns easier to purchase and own.
• Since the Columbine High School shooting in Littleton, Colorado, in 1999, an entire generation has come of age with the prospect of violence hitting their schools. The oldest of those people are sending their own children to schools where shooting drills are a fact of life.
• Texas officials have said that the Uvalde shooting demonstrates a need for more security in schools but that adding metal detectors and more guards do not necessarily make children feel safe, especially in communities where they may have reason to fear the police, too.
• In a congressional hearing this week, lawmakers blasted the FDA for its slow response to reports that an Abbott infant formula plant in Michigan had extreme contamination problems and its handling of the aftermath when that plant closed and formula became scarce. The issue points up difficulties at the FDA when it was trying to deal with the covid pandemic and was also without a permanent leader. The Biden administration was slow to nominate anyone to head the agency; Dr. Robert Califf didn’t take the helm until earlier this year.
• The infant formula problems have renewed a debate about whether food safety should be placed under the purview of a new, separate agency since the FDA is so busy handling drug and medical device issues.
• A report out this week from the Centers for Disease Control and Prevention finds that 1 in 5 adults who get covid will develop longer-term problems that can include neurological issues and some organ disorders. The study of long covid, however, has left many questions unanswered, including whether vaccination reduces the number of cases and how long the problems last.
• The high number of long-covid cases identified in the report suggests that there could be a significant increase in the population of people needing disability services.
• As the country awaits a decision by the Supreme Court on the future of access to abortion services guaranteed by its 1973 Roe v. Wade decision, states continue to enact restrictive laws. Oklahoma’s governor this week signed a law that bans abortion from the time of fertilization. Some companies have pledged to help workers travel to get abortion services, but that may run afoul of states’ efforts. Texas lawmakers say they want to stop businesses from providing that benefit.

Also this week, Rovner interviews Dr. Richard Baron, president and CEO of the American Board of Internal Medicine. Baron co-authored a recent article in the New England Journal of Medicine about how the medical community should deal with doctors who spread medical misinformation on social media.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: “Strangerville” podcast’s “Episode 203: Jacob,” by Jessica and Justin Van Wyen

Joanne Kenen: NBC News’ podcast “Needle In/Tiffany Dover Is Dead*” by Brandy Zadrozny

Anna Edney: ProPublica’s “The Plot to Keep Meatpacking Plants Open During COVID-19,” by Michael Grabell

Rachana Pradhan: The Washington Post’s “We’re Ignoring a Major Culprit Behind the Teen Mental Health Crisis,” by Heather Turgeon and Julie Wright

Also discussed on this week’s podcast:

Vox.com’s “The School Shooting Generation Grows Up,” by Marin Cogan

Stat’s “Viruses That Were on Hiatus During Covid Are Back — And Behaving in Unexpected Ways,” by Helen Branswell

The New York Times’ “More Than 1 in 5 Adult Covid Survivors in the U.S. May Develop Long Covid, a C.D.C. Study Suggests,” by Pam Belluck

The Texas Tribune’s “Businesses That Help Employees Get Abortions Could Be Next Target of Texas Lawmakers if Roe v Wade Is Overturned,” by Zach Despart

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Novavax hitched its wagon to the global coronavirus pandemic. Before most Americans truly grasped the scope of the danger, the small Maryland biotech startup had secured $1.6 billion in U.S. funding for its covid vaccine. Its moonshot goal: delivering 2 billion shots to the world by mid-2021.

Although the U.S. commitment eventually expanded to $1.8 billion, hardly any Novavax shots have found arms due to manufacturing issues, and most of the world has moved on. Novavax stock has plummeted from $290 a share in February 2021 to around $50 recently.

The FDA finally appears poised to authorize the company’s vaccine, however. If it does, Novavax would target the tens of millions of Americans who are not vaccinated against covid-19 or would benefit from boosters but have avoided mRNA vaccines because of health concerns or conspiracy theories about their dangers.

In clinical trials, Novavax’s two-dose vaccine has worked well and had few safety problems. It appears to cause fewer unpleasant reactions — fever, chills, and exhaustion — associated with mRNA vaccines produced by Moderna and Pfizer-BioNTech.

Novavax also relies on a more time-tested technology, using recombinant proteins grown in cell cultures. An influenza vaccine produced much the same way as Novavax’s shot has been on the market in the United States for nearly a decade.

“I do think there is a minority group who would take a protein vaccine over an mRNA vaccine,” said Dr. Kathleen Neuzil, director of the Center for Vaccine Development and Global Health at the University of Maryland. She was a researcher in a major U.S. trial of the Novavax vaccine, which found it 100% effective at preventing anything worse than mild covid.

With the FDA’s authorization, Novavax’s product would be the first vaccine produced in India for U.S. consumption. Novavax turned to the Serum Institute of India, a seasoned manufacturer that makes vaccines for poor countries, when its subcontractor in Texas, Fujifilm Diosynth Biotechnologies, stopped producing the vaccine last summer after it was dinged by FDA inspectors for inadequate contamination control, missing records, and other problems.

Founded in 1987, Novavax has never marketed a vaccine in the United States. It has boasted about the potential of a secret proprietary ingredient, Matrix-M, an immune system booster derived from Chilean soapbark trees. Those who’ve observed the company’s string of failures over the past decade see its June 7 FDA advisory committee meeting as the last chance to market its covid vaccine here, although it has obtained more than $2 billion in contracts with the U.S. government and nonprofit organizations.

Pharma giants Sanofi and GSK are jointly developing a similar vaccine. European Union reviewers began an examination of the drugmakers’ vaccine in March, and the companies expect to request an FDA review “in coming weeks,” Sanofi spokesperson Sally Bain said.

Even with FDA authorization, Novavax may be too late. While its vaccine is licensed in 41 countries and at least 42 million doses have been distributed, the world is overstocked with covid vaccine.

“They are applying for an emergency authorization” from the FDA, said Manon Cox, a vaccine industry consultant and the former CEO of Protein Sciences Corp., which made a similar vaccine. “What’s the emergency?”

Demand for covid vaccines is sluggish everywhere. About 13 million doses of the Novavax vaccine had been distributed in European Union countries as of mid-April, but fewer than 200,000 were administered. Distribution of the vaccine has been negligible since then.

Gavi, a nongovernmental organization, has suspended a 2021 agreement to buy at least 350 million Novavax doses for the COVAX program, which distributes vaccines at a deep discount to poor countries.

The U.S. market, however, shows promise for Novavax’s shot as an alternative to mRNA vaccines, especially now that the FDA has limited the use of a fourth vaccine, made by Johnson & Johnson, because of a serious though rare safety risk.

“The anti-vaxxers have been getting more and more aggressive about mRNA vaccine safety, including in recent months claiming these vaccines cause AIDS,” said John Moore, a professor of microbiology and immunology at Weill Cornell Medicine. “It’s all utter BS. But some people do buy into this garbage.”

Neuzil said the Novavax shot could prove more durable than the mRNA shots, whose capacity to prevent infection seems to fade after several months, although they are effective at keeping people out of the hospital.

“Realistically, there probably aren’t that many unvaccinated people who will now decide to take Novavax,” Moore said. “Being unvaccinated is mostly down to politics, not science, sadly.”

Most of the demand would be for boosters. But the FDA has indicated Novavax’s shots would be authorized initially as a first dose, not a booster, John Trizzino, Novavax’s chief commercial officer, told KHN in an interview. FDA officials also have bruited the possibility of requiring vaccine manufacturers to modify their shots by this fall to target the omicron variant.

Novavax has data showing its shot effectively boosts people who received mRNA vaccines, Trizzino said. And although the company is skeptical about the need to modify its shot, Novavax recently began testing an omicron-targeted vaccine and expects results in late summer, he said.

It’s surprising that Novavax should face this quandary now. The company announced May 9 that it had made its first-ever quarterly profit, of $203 million on $586 million in vaccine sales.

Novavax expects revenue of $4 billion to $5 billion this year in global sales, Trizzino said, noting “this is not just a pandemic question, it’s an ongoing vaccination question.” At an April 6 meeting, federal officials strongly suggested that covid vaccination will become an annual recommendation, like the flu shot.

“We were slightly behind providing supply into the pandemic period, unfortunately,” Trizzino said, “but there’s going to be at least some kind of annual revaccination.”

Trizzino said the company was negotiating with U.S. officials on how much of the remainder of its $1.8 billion contract would pay for shots as opposed to research. Beyond the contract, Novavax can charge the U.S. government a higher per-unit price for additional vaccine, he said.

The Biden administration’s budget contains no mention of further Novavax contracts, but if federal purchases end, Novavax could sell on the commercial market. Medicare officials have set the price for covid vaccines at about $60 per dose — approximately three times what Novavax has been getting from the U.S. and European government buyers, Trizzino said.

The company has come a long way from its first product, a microscopic fat particle designed to encase vaccines that instead was employed in skin care products and Girl Scout cookies, according to “The First Shots,” an account by journalist Brendan Borrell. Novavax spent hundreds of millions to develop a vaccine against respiratory syncytial virus, an infection that is especially harmful to babies and the elderly, but the product failed in 2016, after the company brushed aside a design feature originating in the National Institutes of Health laboratory of Dr. Barney Graham. That feature, which involves shaping the viral protein to allow the immune system to better recognize it, is now a key part of all the U.S. covid vaccines, including the Novavax shot.

In 2019, Novavax sold its vaccine production facility and laid off all but about 100 employees. A year later it was revived by Operation Warp Speed, the massive public-private effort to produce covid vaccines.

To make its shot, the company genetically alters an insect virus called a baculovirus to produce covid proteins in moth cells. The system was developed by Gale Smith, first at Protein Sciences Corp., which used it to license an influenza vaccine. Sanofi in 2017 bought Protein Sciences and its vaccine.

Smith, who has worked at Novavax since 2003, saw the moth cell system as a safer, faster alternative to traditional methods of growing vaccine viruses in eggs or monkey and dog kidney cell cultures, which were prone to contamination with potentially dangerous viruses. Baculoviruses don’t grow in people.

But the baculovirus system is messy, according to Kevin Gilligan, a senior consultant at Biologics Consulting Group in Alexandria, Virginia, and a former federal pandemic preparedness official. The product of the moth cell bioreactors can be a sticky mixture of cellular debris, and insect and viral proteins.

“It’s a whole soup of all kinds of things,” Cox said. “You go through a purification process and hopefully end up with that 90-plus percent pure protein you want.”

According to one report, some lots produced at the Texas plant were only 70% pure. So Novavax turned to the Serum Institute of India, one of several companies in the U.S., Asia, and Europe with which it had signed manufacturing agreements in 2020.

In the meantime, Novavax’s executives reaped record payouts in 2020. CEO Stanley Erck got $48 million, mostly in stocks and bonuses, while Trizzino and others got payouts of $20 million or more each. Over the past year, company executives cashed out stocks worth more than $150 million.

Shareholders have sued Novavax over sagging stock prices following missed deadlines for its vaccine.

In June 2021 Novavax hired a leading process engineer, Indresh Srivastava, from Sanofi. The company’s manufacturing problems are “well past us,” Trizzino said.

In an unusual twist, while U.S. taxpayers may come to rely on the Indian version of a vaccine they heavily funded, another Indian company, Biological E, is making a vaccine invented by Peter Hotez, Maria Elena Bottazzi, and colleagues at Baylor College of Medicine. Their only government funding was a $400,000 NIH grant, Hotez said, and Baylor is giving the shot away to companies that will make it cheaply in lower-income countries.

About 45 million doses of the vaccine have been administered so far to Indian teens — with a cost to the Indian government of $1.86 per shot.

KHN correspondent Rachana Pradhan contributed to this report.

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By Hannah Norman

May 26, 2022

<br /> <span class="byline">Hannah Norman, Kaiser Health News</span></p> <p>Just as covid-19 vaccines were rolling out, Dr. Taison Bell <a rel="nofollow" href="https://khn.org/news/article/black-americans-are-getting-vaccinated-at-lower-rates-than-white-americans/">spoke with KHN</a> about why Black Americans were getting vaccinated at lower rates than white Americans were. More than a year later, we checked in with Bell, an assistant professor of medicine and an intensive care unit doctor at the University of Virginia, about the state of the pandemic and changes that have occurred in the health equity conversation since then. </p> <p>This video is part of KHN’s new “Spotlight” interview series, which aims to amplify the voices of health experts, patients, and really anyone interacting with the U.S. health care system. </p> <p><a rel="nofollow" href="https://khn.org/about-us">KHN</a> (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at <a rel="nofollow" href="https://www.kff.org/about-us/">KFF</a> (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.</p> <h3>USE OUR CONTENT</h3> <p>This story can be republished for free (<a rel="nofollow" href="https://khn.org/news/article/california-covid-outbreak-mask-mandates-schools/view/republish/">details</a>).</p> <p>Copy HTML

Police suspect arson was behind a fire that damaged a clinic under construction in Casper that would become Wyoming’s sole site for procedural abortions.

A caller phoned 911 shortly before dawn Wednesday to report seeing someone with a gas can running away from the building near downtown Casper. Smoke billowed from the building’s windows by the time authorities arrived, Casper police said.

The facility appears to have internal damage, one of its organizers said later Wednesday. Wellspring Health Access, the nonprofit developing the clinic, plans to make repairs. But founder Julie Burkhart said whether the clinic will open on schedule in June is unclear. “I’m just really sad and angry that people would take it upon themselves to try to shut us down this way,” Burkhart said, speaking by phone from outside the building.

Even before the fire, the clinic’s future was unclear. Wellspring is moving forward with its plan despite an imminent U.S. Supreme Court decision expected to reverse constitutional protections for abortion rights provided by the landmark 1973 case Roe v. Wade. A recently enacted “trigger law” in Wyoming would take effect days after such a ruling, banning most abortions in the state.

Burkhart said Wednesday that she’s glad no one was hurt by the fire. 

She said the building contains some furniture, exam tables, and medical equipment. She suspects the inside of the building has fire and smoke damage, since the walls appeared blackened.

Bob Brechtel, who has helped organize anti-abortion prayer vigils outside the Casper site, condemned the suspected arson. “We’re really sorry that this thing happened,” said Brechtel, who previously served as a Republican state legislator. “Something like this is of no help to us or anybody else. Damaging somebody else’s property will not fix anything, so we certainly would not condone it in any respect.”

Brechtel said people who attend the weekly vigils are asked to sign a document promising to be peaceful and to allow people access to the facility.

Burkhart said local police and the U.S. Bureau of Alcohol, Tobacco, Firearms and Explosives were at the scene Wednesday. She hopes the clinic’s surveillance cameras captured images of the suspected arsonist.

Casper police spokesperson Rebekah Ladd said investigators are examining footage from the cameras. If they find clear images of the suspect, they will ask the public to help identify the person.

Wyoming’s only other clinic that offers abortions is in Jackson — a five-hour drive to the west — and it offers only medication abortions up to 10 weeks of gestation.

The new Casper clinic plans to offer medication and procedural abortions. It would become the nearest place to get an abortion for many people in what the nonprofit’s founders describe as an “abortion desert,” stretching from eastern Wyoming into western Nebraska and South Dakota.

This is not the first time clinics that offer abortions have been targeted. A Planned Parenthood clinic in Tennessee was destroyed in an intentional fire on New Year’s Eve. Years earlier, the man behind the fatal bombing at the 1996 Atlanta Olympics also bombed two clinics that provided abortions.

Meanwhile, an anti-abortion group’s office in Wisconsin was recently targeted with Molotov cocktails. An abortion-rights group has claimed responsibility, but police have made no arrests.

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BROWNING, Mont. — As the pandemic was setting in during summer 2020, Justin Lee Littledog called his mom to tell her he was moving from Texas back home to the Blackfeet Indian Reservation in Montana with his girlfriend, stepson, and son.

They moved in with his mom, Marla Ollinger, on a 300-acre ranch on the rolling prairie outside Browning and had what Ollinger remembers as the best summer of her life. “That was the first time I’ve gotten to meet Arlin, my first grandson,” Ollinger said. Another grandson was soon born, and Littledog found maintenance work at the casino in Browning to support his growing family.

But things began to unravel over the next year and a half. Friends and relatives saw Littledog’s 6-year-old stepson walking around town alone. One day, Ollinger received a call from her youngest son as one of Littledog’s children cried in the background. He was briefly unable to wake Littledog’s girlfriend.

Ollinger asked Littledog whether he and his girlfriend were using drugs. Littledog denied it. He explained to his mom that people were using a drug she had never heard about: fentanyl, a synthetic opioid that is up to 100 times as potent as morphine. He said he would never use something so dangerous.

Then, in early March, Ollinger woke up to screams. She left her grandchildren sleeping in her bed and went into the next room. “My son was laying on the floor,” she said. He wasn’t breathing.

She followed the ambulance into Browning, hoping that Littledog had just forgotten to take his heart medication and would recover. He was pronounced dead shortly after the ambulance arrived at the local hospital.

Littledog was among four people to die from fentanyl overdoses on the reservation that week in March, according to Blackfeet health officials. An additional 13 people who live on the reservation survived overdoses, making a startling total for an Indigenous population of about 10,000 people.

Fentanyl has taken root in Montana and in communities across the Mountain West during the pandemic, after formerly being prevalent mostly east of the Mississippi River, said Keith Humphreys of the Stanford-Lancet Commission on the North American Opioid Crisis.

Montana law enforcement officials have intercepted record numbers of pale-blue pills made to look like prescription opioids such as OxyContin. In the first three months of 2022, the Montana Highway Patrol seized over 12,000 fentanyl pills, more than three times the number from all of 2021.

Nationwide, at least 103,000 people died from drug overdoses in 2021, a 45% increase from 2019, according to data from the Centers for Disease Control and Prevention. About 7 of every 10 of those deaths were from synthetic opioids, primarily fentanyl.

Overdose deaths are disproportionately affecting Native Americans. The overdose death rate among Indigenous people was the highest of all racial groups in the first year of the pandemic and was about 30% higher than the rate among white people, according to a study co-authored by UCLA graduate student and researcher Joe Friedman.

In Montana, the opioid overdose death rate for Indigenous people was twice that of white people from 2019 to 2021, according to the state Department of Public Health and Human Services.

The reason, in part, is that Native Americans have relatively less access to health care resources, Friedman said. “With the drug supply becoming so dangerous and so toxic, it requires resources and knowledge and skills and funds to stay safe,” he said. “It requires access to harm reduction. It requires access to health care, access to medications.”

The Indian Health Service, which is responsible for providing health care to many Indigenous people, has been chronically underfunded. According to a 2018 report from the U.S. Commission on Civil Rights, IHS per patient expenditures are significantly less than those of other federal health programs.

“I think what we’re seeing now is deep-seated disparities and social determinants of health are kind of bearing out,” Friedman said, referring to the disproportionate overdose deaths among Native Americans.

Blackfeet Tribal Business Council member Stacey Keller said she has experienced the lack of resources firsthand while trying to get a family member into treatment. She said just finding a facility for detoxing was difficult, let alone finding one for treatment.

“Our treatment facility here, they’re not equipped to deal with opioid addiction, so they’re usually referred out,” she said. “Some of the struggles we’ve seen throughout the state and even the western part of the United States is a lot of the treatment centers are at capacity.”

The local treatment center doesn’t have the medical expertise to supervise someone going through opioid withdrawal. Only two detox beds are available at the local IHS hospital, Keller said, and are often occupied by other patients. The health care system on the reservation also doesn’t offer medication-assisted treatment. The nearest locations to get buprenorphine or methadone — drugs used to treat opioid addictions — are 30 to 100 miles away. That can be a burden to patients who are required by federal rules to show up each day at the approved dispensaries to receive methadone or must make weekly treks for buprenorphine.

Keller said tribal leaders have requested assistance from IHS to build out treatment and other substance use resources in the community, with no results.

The IHS’ Alcohol and Substance Abuse Program consultant, JB Kinlacheeny, said the agency has largely shifted to appropriating funds directly to tribes to run their own programs.

The Rocky Mountain Tribal Leaders Council, a consortium of Montana and Wyoming tribes, is working with the Montana Healthcare Foundation on a feasibility study for a treatment center operated by tribes to build capacity specifically for tribal members. Tribes across both states, including the Blackfeet, have passed resolutions supporting the effort.

Blackfeet political leaders declared a state of emergency in March after the fentanyl overdoses. A short time later, some of the tribal council chairman’s children were arrested on suspicion of selling fentanyl out of his home. The council removed Chairman Timothy Davis from his position as tribal leader in early April.

The tribe has created a task force to identify both the short- and long-term needs to respond to the opioid crisis. Blackfeet tribal police investigator Misty LaPlant is helping lead that effort.

Driving around Browning, LaPlant said she plans to train more people on the reservation to administer naloxone, a medication that reverses opioid overdoses. She also wants the tribe to host needle exchanges to reduce infections and the spread of diseases like HIV. There’s also hope, she said, that a reorganization of the tribal health department will result in a one-stop shop for Blackfeet Nation residents to find drug addiction resources on and off the reservation.

However, she said resolving some of the underlying issues — such as poverty, housing, and food insecurity — that make communities like the Blackfeet Nation vulnerable to the ongoing fentanyl crisis is a massive undertaking that won’t be completed anytime soon.

“You could connect historical trauma, unresolved traumas in general, and grief into what makes our community vulnerable,” she said. “If you look at the impact of colonialism and Indigenous communities and people, there’s a correlation there.”

Marla Ollinger is happy to see momentum building to fight opioid and fentanyl addiction in the wake of her son’s death and other people’s. As a mother who struggled to find the resources to save her son, she hopes no one else has to live through that experience.

“It’s heartbreaking to watch your children die unnecessarily,” she said.

This story is part of a partnership that includes Montana Public Radio, NPR and KHN.

Arielle Zionts

CASPER, Wyo. — A modest, tan building sandwiched between a gas station and a small apartment house near this Western city’s downtown has become an unexpected focal point of America’s abortion debate, just weeks before Wyoming could outlaw the procedure.

Inside, a nonprofit is renovating the space into a clinic that, beginning in June, would be the only one in Wyoming to provide procedural abortions. The Casper clinic also would become the closest option for people in what the nonprofit’s founders describe as an “abortion desert,” extending into western Nebraska and South Dakota.

Outside, on a recent Thursday, more than 100 abortion opponents gathered for a prayer vigil on the sidewalk along a busy five-lane street. A smaller group of vocal abortion rights advocates assembled nearby.

The protest groups congregate weekly as work to open the clinic continues, despite an imminent U.S. Supreme Court decision expected to reverse constitutional protections for abortion rights provided by the landmark 1973 case Roe v. Wade. A recently passed “trigger law” in Wyoming would take effect days after such a ruling, banning most abortions in the state.

Teens, young adults, parents with small children, and seniors silently held signs emblazoned with Bible verses or slogans, such as “Abortion hurts women,” during the recent vigil.

One man walked through the crowd yelling anti-religious slogans, while a group of teens took a less confrontational approach to counter the vigil’s message by chanting “My body, my choice.”

Several drivers passing by honked in support of the anti-abortion group or yelled expletives and, “It’s my body!”

The opposing groups of demonstrators don’t see eye to eye on much, but they seemed to agree on one thing: They’re surprised the clinic is opening in Wyoming, an overwhelmingly Republican state where 70% of voters supported Donald Trump in the 2020 presidential election — the highest percentage of any state.

“I never thought I would see an abortion clinic come to Wyoming, let alone Casper, just because it is more conservative,” 39-year-old Robin Holmes said during the vigil.

Holmes wore a custom T-shirt and held a homemade poster, both saying “Unborn Lives Matter.” She said her daughter became pregnant in her teens but decided against abortion and is now raising the child.

Rikki Hayes, who supports the new clinic, found a piece of cardboard on her way to the vigil and held it up after writing “Mind your own business!”

“I didn’t think in a million years that we, in Casper, would ever get one. We’re in Wyoming,” said Hayes, a 21-year-old coffee shop manager.

The idea to open a clinic in Casper came from Wyoming activist Christine Lichtenfels. She shared her suggestion with Julie Burkhart, a Colorado resident and veteran of the national abortion rights movement

The only other Wyoming clinic offering abortions is in Jackson, a five-hour drive west of Casper and near the Idaho border. It offers only medication abortions up to 10 weeks of gestation.

“I just thought, ‘Gosh, why can’t we get something in Casper?’ It’s the perfect location, pretty much in the center,” Lichtenfels said.

Burkhart agreed and founded the nonprofit Wellspring Health Access in May 2021 to open the clinic and plan other projects aimed at expanding access to abortion. Lichtenfels is an attorney and board member of Chelsea’s Fund, a nonprofit that provides financial assistance for Wyoming residents seeking abortions. She said taking a day or more to travel to an appointment creates logistical and financial burdens for many people.

“You have a job, maybe you’ve got kids, so you’ve got to find kid care,” Lichtenfels said. “Maybe you don’t have a great car, maybe you don’t have a car. Or maybe the roads are closed.”

Casper, with a population of about 59,000, is a three- or four-hour drive north or south from the nearest clinics — one in Billings, Montana, and another in Fort Collins, Colorado. It’s also relatively close to regions of neighboring states without abortion services.

Some people in western South Dakota seeking abortions now drive five hours to clinics in Montana or Colorado. If they stay within South Dakota, they must travel four hours to Sioux Falls, where they face a three-day waiting period.

When organizers began planning the clinic, Wyoming had fewer abortion restrictions than many other Republican-controlled states.

Wyoming allows abortion up to viability (about 24 weeks) and has no ban on telemedicine abortions. It has no mandated waiting period, doesn’t require doctors to read specific information to patients, and doesn’t require patients to view an ultrasound. Still, the state remained largely devoid of abortion services.

Then, in March, Wyoming became the 13th state to pass a “trigger law.” The law would make abortions illegal five days after Roe v. Wade is overturned, with exceptions in cases of pregnancies involving rape, incest, or risk to the mother’s life.

Similar laws are on the books in Idaho, North Dakota, South Dakota, and Utah. Policy watchers expect Montana and Nebraska lawmakers also will pursue abortion bans. That means many people from this region would need to drive or fly to other states for abortion services if Roe v. Wade is overturned.

No matter what the U.S. Supreme Court decides, the public debate will continue in Wyoming, both sides say.

Burkhart said legal challenges could slow Wyoming’s trigger law from taking effect. Even if the state outlaws abortion, she hopes the clinic will stay open to offer its other services, such as gynecology, testing for sexually transmitted infections, family planning, and gender-affirming care for LGBTQ+ patients.

She also expects Wellspring Health Access will explore ways to help people in states with abortion bans find services in neighboring states, including opening clinics near state borders or bringing mobile clinics or telemedicine services to those areas.

Burkhart said it may also be possible to bring mobile clinics into states with abortion bans, to screen, prep, and enroll people for out-of-state appointments.

Local anti-abortion activists say that even if Wyoming bans abortion, their campaign won’t end. Bob Brechtel is a Republican former state legislator who helps organize the weekly prayer vigils outside the Casper clinic.

“Rule of law is important, but what’s more important is that we do have people who are accepting and understanding of our purpose to defend human life at all stages,” he said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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