Author: books

When Dani Yuengling felt a lump in her right breast last summer, she tried to ignore it.

She was 35, the same age her mother had been when she received a breast cancer diagnosis in 1997. The disease eventually killed Yuengling’s mom in 2017.

“It was the hardest experience, seeing her suffer,” said Yuengling, who lives in Conway, South Carolina.

After a mammogram confirmed the lump needed further investigation, Yuengling scheduled a breast biopsy for Valentine’s Day this year at Grand Strand Medical Center in Myrtle Beach.

Among many concerns she had ahead of that appointment — the first being a potential cancer diagnosis — Yuengling needed to know how much the biopsy would cost. She has a $6,000 annual deductible — the amount her health plan requires she pay before its contribution kicks in — and she wasn’t close to hitting that. Whatever the procedure cost, Yuengling knew she’d be on the hook for most of it.

But the hospital wouldn’t give her a price. She was told her providers wouldn’t know what type of biopsy needle they needed until the procedure was underway and that would impact the price.

The hospital’s online “Patient Payment Estimator” showed that an uninsured patient would owe about $1,400 for the procedure.

“That’s fine. No big deal,” she thought to herself, confident it would be cheaper for her because she did have insurance. A Google search indicated it could be closer to $3,000, but Yuengling thought that price seemed reasonable, too. She wasn’t fretting too much about money as she underwent the procedure.

It soon brought the good news that she didn’t have cancer.

Then the bill came.

The patient: Dani Yuengling, now 36, who is covered by Cigna through her employer, a human resources contractor for the Mayo Clinic.

Medical service: An ultrasound-guided breast biopsy.

Service provider: Grand Strand Medical Center, a 403-bed, for-profit hospital in Myrtle Beach, South Carolina. It is one of 182 hospitals owned by Nashville-based HCA Healthcare, which generated $58.7 billion in revenue last year.

Total bill: $17,979 for the procedure, including lab work, pharmacy charges, and sterile supplies. Cigna’s in-network negotiated rate was $8,424.14, of which the insurance company paid the hospital $3,254.47. Yuengling was billed $5,169.67, the balance of her deductible.

What gives: It’s not uncommon for uninsured patients — or any patient willing to pay a cash price — to be charged far less for a procedure than patients with health insurance. For the nearly 30% of American workers with high-deductible plans, like Yuengling, that means using insurance can lead to a far bigger expense than if they had been uninsured or just pulled out a credit card to pay in advance.

Ge Bai, an associate professor at Johns Hopkins Bloomberg School of Public Health, recently published research on this topic and said hospitals in the U.S. often set their cash prices lower than the prices they charge to treat commercially insured patients.

“We can very confidently say this is very common,” said Bai, who advised that all patients, regardless of their insurance status, inquire about the cash price before undergoing a procedure. “It should be a norm.”

Grand Strand charged Yuengling’s insurance an extraordinarily high price for her procedure. By comparison, according to the federal government’s website, Medicare patients who need an ultrasound-guided biopsy similar to the one Yuengling received would pay only about $300 — their required 20% coinsurance for outpatient care. Medicare would pay the hospital the remainder of the bill, about $1,200. The hospital expected more than five times the Medicare price from Yuengling and her insurer.

Patients in Conway with private health insurance who are treated at other hospitals also typically are charged less than what Yuengling paid for the same procedure — on average about $3,500, according to Fair Health Consumer, an organization that analyzes health insurance claims.

And uninsured patients who pay cash prices and need an ultrasound-guided breast biopsy at the nearby Conway Medical Center are likely to owe even less — about $2,100, according to Allyson Floyd, a spokesperson for the hospital.

Meanwhile, Grand Strand Medical Center spokesperson Caroline Preusser blamed “a glitch” involving the hospital’s online calculator for the inaccurate information Yuengling received and said the correct estimate for the cash price for a breast biopsy at the hospital is between $8,000 and $11,500 “depending on the exact procedure and equipment used.”

The hospital removed certain procedures from the payment estimator until they can be corrected, Preusser wrote. She did not say how long that would take.

Resolution: Yuengling tried disputing the charges with the hospital. She called the billing department and was offered a 36% discount, lowering the amount she needed to pay to $3,306.29. Grand Strand Medical Center allows patients to set up payment plans, but Yuengling decided to charge the full amount to a credit card because she wanted the whole thing to go away.

“I could not sleep. It was driving me crazy. I was having migraines. I was sick to my stomach,” she said. “I hate having debt. I didn’t want to think about it. Obviously, that didn’t work because I’m still thinking about it.”

She said she requested on multiple occasions to speak to the hospital’s patient advocate and was eventually connected with an outside company, Parallon, which conducted an audit of her bill. She eventually received a letter dated May 26 from the hospital’s Revenue Integrity Department. It stated: “After a review of the charges in question and your medical record, the following was identified; The charges on your account were appropriate.”

“I don’t know why I actually expected a different outcome,” she said.

The hospital has requested that Yuengling return for a follow-up appointment related to the biopsy. She has refused.

Harlow Sumerford, a spokesperson for HCA Healthcare, told KHN in an email that the hospital system apologizes for any confusion caused by the payment estimator “and we are working to fix the issue.”

The takeaway: With a family history of breast cancer, Yuengling was right to follow up with her doctor after feeling a lump. After failing to get a clear answer on her costs from Grand Strand Medical Center, she could have taken an additional step to explore what other hospitals in the area charge. Although her physician referred her to Grand Strand, she was not obligated to use that hospital. She could have saved a significant amount of money by opting to undergo the procedure elsewhere.

Furthermore, patients like Yuengling who have a high-deductible insurance plan should consider paying cash prices for certain procedures and not involving their insurance company at all.

Jacqueline Fox, a health care attorney and a professor at the University of South Carolina School of Law, said she isn’t aware of any law that would prohibit a patient from doing that. After all, she pointed out, patients with health insurance pay cash prices for prescription medications all the time. It stands to reason they could do the same for medical procedures.

But some facilities make this difficult. Grand Strand Medical Center, for example, offers “self-pay” patients an “uninsured discount,” but that discount is limited to people who have “no third party payer source of payment or do not qualify for Medicaid, Charity or any other discount program the facility offers,” according to the hospital’s website. Only patients confirmed to have no health insurance are offered information about the discount.

In some cases, paying a cash price for a procedure might not make financial sense in the long run because none of it would be applied toward the deductible. Patients might save money on one procedure but end up paying their full deductible if unexpected medical expenses mount later during the calendar year.

Insured patients should reach out to their health plan for a good-faith estimate before a procedure. Under the No Surprises Act, health plans are supposed to give members an idea of their total out-of-pocket costs upon request. Ask for an “Advanced Explanation of Benefits,” said Sabrina Corlette, a research professor at the Georgetown University McCourt School of Public Policy, though she points out this part of the law isn’t being enforced yet.

The No Surprises Act also allows patients to file complaints with the federal government regarding their medical bills — whether or not they carry health insurance.

Yuengling filed her complaint in June.

Stephanie O’Neill contributed the audio portrait with this article.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. It is an editorially independent major operating program of KFF (Kaiser Family Foundation).

Polio is the disease most people thought we had put behind us here in the United States. But earlier this summer, an individual in Rockland County, N.Y., contracted the virus likely from exposure in this country, and ended up paralyzed.

The last time there was community transmission of polio in the U.S. was 1979. The Americas were declared polio free in 1994. Though it’s just one case of paralysis at the moment, public health officials — both locally and nationally — are taking the news very seriously.

Wastewater testing and genetic sequencing have shown the virus has been quietly circulating in a couple New York counties since at least May. And it recently was detected in New York City’s wastewater. “Even a single case of paralytic polio represents a public health emergency in the United States,” the Centers for Disease Control and Prevention declared in a recent report.

Low vaccination rates in Rockland county mean there’s a risk of more paralytic cases in that community, the report said. The challenges that health officials are facing while managing the local response in New York may indicate where other spots in the country could soon be headed.

“Rockland County is basically New York City,” says Perry Halkitis, dean of the School of Public Health at Rutgers University. “New York City is basically New Jersey. Rockland County is basically Connecticut.” Because people travel so much, diseases like polio can spread quickly, he explains. “Are there probably dozens, if not hundreds, if not more cases of undetected polio in our population? Probably. Are we catching them? Probably not.”

And health officials have to tackle this outbreak in a moment of rising wariness towards public health fueled by the COVID crisis.

A feeling of dread

The news about the paralytic case circulated amongst those in local government before it was announced to the public. Mona Montal — chief of staff for the town of Ramapo in Rockland county — remembers what went through her head: “Here we go again.” She was, of course, thinking of the grueling last two plus years of combatting COVID. “Do I as an individual, and do we collectively, as a county and as a community, have the strength to go through this again?,” she wondered.

And polio, with its possibility of paralysis, is an especially terrifying disease. “Polio cannot be cured,” Montal explains. “And once it’s paralytic polio, you’re paralyzed. Plain and simple.”

Before the vaccine was rolled out across the U.S., paralysis and children in braces and wheelchairs were among the haunting images of outbreaks from the 1940s and 50s. In fact, Montal was told stories of her own family members who died or were paralyzed by the disease.

During COVID, she worked on the county’s COVID vaccine information campaign, alongside Rockland County resident Shoshana Bernstein, an independent health communicator. The news of paralytic polio had Bernstein in knots. “I’ll check my phone about seven times a night,” she says. “I wake up like, ‘Oh my God, is there another case?'”

A very small percentage of people with polio become paralyzed. Most of the time, there are no symptoms at all. Which is why, in public health, just one case of paralytic polio constitutes an outbreak — the tip of the iceberg.

“It’s very difficult to predict how many people, but it’s definitely a number of individuals that would have to be actively transmitting,” says Dr. Irina Gelman, Commissioner of Health, Orange County, which is next door to Rockland. “Clearly a confirmed case of polio in the United States is major news.”

When Rockland and Orange Counties started testing the wastewater for polio, samples going back to May were positive for polio. Then, sequencing the virus’ genetic material surfaced something else that was unsettling.

“There are multiple strains, so they are different,” says Gelman, “meaning we do know that it’s more than one individual” who is shedding polio virus. In other words, the outbreak isn’t contained.

The risk of low vaccination rates

Falling vaccination rates are a big part of the problem, in the U.S. and abroad. During the pandemic, many children missed shots and vaccine services were disrupted, the CDC notes in its report on the Rockland polio case. Nationally, by age two, nearly 93% of infants born during 2017-2018 were vaccinated for polio. But according to the New York State Immunization Information System, vaccination coverage among infants and children less than 24 months living in Rockland County was 60.3% in August 2022. In some communities, coverage was as low as 37.3%.

“I mean, to put it bluntly, it’s just disappointing at this point that we are still here,” Gelman says. “This is a vaccine-preventable disease. And had everyone just been up-to-date on their vaccination, we would have continued to report it as being eradicated.”

Here’s how authorities think the virus got here:

A person came to New York State infected with a strain of polio which is connected to samples found in the wastewater of Israel and the UK. The person didn’t realize they had polio: They didn’t have symptoms, or they were mild or generic. Then, because vaccination levels are low in some communities in New York State, the virus started spreading, eventually causing paralysis in a person in Rockland. The virus then continued to fan out, since Rockland and Orange Counties have some of the lowest polio vaccination rates for young kids in the country.

“It’s a multitude of reasons spread across a multitude of demographics,” says Bernstein. “There’s no one single group that is not vaccinated.” This is true not just of these communities in and around New York City.

“We have a large number of…populations who are choosing not to vaccinate [their children],” says Halkitis. “And so it is a reality across our country. We know from territory to territory, from borough to borough, from neighborhood to neighborhood, there’s wide variation right now.”

That is, although polio has only been detected in these few places in New York State so far, Halkitis warns it’s likely to spread to other places near and far with pockets of low vaccination.

Tackling vaccine hesitancy

If polio does show up in other places in the U.S., they are likely face some of the same challenges Rockland and Orange Counties have encountered in reaching communities that are under-vaccinated.

Bernstein explains that COVID and all the talk of vaccinations just made everyone tired and confused in Rockland County. She’s a member of the large ultra-Orthodox Jewish population here, some of whom, she says, choose to live a more insular lifestyle.

“Social and secular media is not really something that’s brought in,” Bernstein says. “So it’s a lot of word of mouth,” which, she acknowledges, makes some within her community vulnerable to anti-vaccine messaging. “We always say it’s extremely easy to instill fear and extremely difficult to undo it,” says Bernstein.

The county is a mosaic of people where vaccination rates are also low, including members of the Haitian and Latino communities. “I think any press release from the CDC is just — no one’s even reading it,” Bernstein says.

So Bernstein and Montal have joined forces to become a vital conduit between all the official public health language and the hearts and minds of their neighbors. The duo helped initiate a large printed infographic, which is hot off the presses. There are four versions in English, Spanish, Haitian Creole, and Yiddish. Montal says it’s carefully worded.

“People have had PTSD with the word vaccination,” Montal explains. “So we’re immunizing, we’re not vaccinating. And that’s the messaging.”

The two women work with trusted community leaders, like rabbis and pastors, to get the word out. And they’ve asked the CDC for a letter they can show these leaders that supports them in that effort.

“My dream is that after this,” says Bernstein, “the CDC will actually have like a game plan of, ‘Okay, we’re using Rockland County as our model. And now we’re going to repeat that model across the country.'”

The Rockland County Department of Health has organized a variety of polio-only immunization clinics in different locations once or twice a week. Montal says, “We have to bring the immunizations to the people. We can’t expect the people to come to us.”

To that end, last Wednesday afternoon in Spring Valley, at a polio immunization clinic, a total of about 15 people stopped by over a couple hours. Brian Hastings drove two hours from Long Island for a shot. Dolores Thaxton, who’s 89 years old, was never vaccinated for polio and decided to roll up her sleeve.

This kind of outreach is a long-term effort, that may slowly pay off. Abigail Guerrero, a young mother from Ecuador who speaks very little English, came to the clinic for something else but saw the large infographic in Spanish taped up — the one that Bernstein and Montal helped make. This sign was her first encounter with the polio outbreak in her community and after reading it and learning about the disease, she decided to get immunized.

Back in Orange County, Commissioner of Health Dr. Irina Gelman says she’s a sound sleeper, because she doesn’t get much of it. She’s up at 3:30 every morning. The drumbeat of disease hasn’t let up since she began her job four years ago.

“We started with the measles outbreak,” she says. “And we’ve gradually progressed into COVID 19. And simultaneously, we are now dealing with monkeypox. And with now polio. It was officially eradicated, yes. It does pose a tremendous amount of concern.”

On a Friday evening at a call center in southeastern Pennsylvania, Michael Colluccio stirs his hot tea, puts on his headset, and starts up his computer. On the screen, calls are coming in to the suicide prevention lifeline from around the state.

The 38-year old Colluccio says he knows what it’s like to be on the other end of one of those calls.

“So I had a suicide attempt when I was about 10, 11 years old,” Colluccio says. “And we do get callers who are about that age, or quite young, and they are going through similar stressors.”

For people having a mental health crisis, calling 988 can be a life-saving decision. But what happens after you call depends on where you are. The new 988 system launched in mid-July, and one early estimate says calls went up 45% nationally during the first week.

With calls expected to increase more as people learn about the helpline, some call centers say there are limits to what they can accomplish without more local resources.

Colluccio says callers in this area — Bucks County, a suburb of Philadelphia — have access to more services than in many parts of the state. His job with the Family Service Association, which runs the hotline, sometimes involves connecting them with services such as homeless shelters, therapists or drug and alcohol counselors.

More than anything, his job is to listen.

‘If you did not pick up, I’d have killed myself’

Colluccio’s first call of the evening is from a woman who sounds panicked. Her partner has been using drugs and has started making violent threats.

He spends a lot more time listening than talking. He says by listening closely to what she has to say, he offers relief, validation and human connection.

When he does talk, he usually asks questions — gently searching for specific ways to help. In this case, his questions lead him to connect the caller with local domestic abuse services and a social worker.

One service he rarely turns to is 911. Part of the idea behind 988 is that it offers an alternative to involving police or an ambulance for a mental health crisis. He would typically use 911 only if someone was an immediate threat to themselves or others.

After talking with the woman for a half hour, Colluccio asks her a few key questions to determine whether she feels suicidal. Colluccio says this is an important step to make sure each caller is safe after they hang up.

What happens next is surprisingly common. At the start of the call it seemed like the woman wanted help for her partner. But when he asks her directly on a scale of one to five how suicidal she is, she says she’s a two or maybe a three — and she’s attempted suicide before.

Before they end the call, Colluccio asks her if she would like a call back tomorrow. She says yes, so he schedules one.

Colluccio has just enough time for a sip of tea when another call comes in. It’s a young man in college, overwhelmed by stress. They talk for over an hour.

This is a pretty typical evening.

“Sometimes it’s more of an immediate intervention because sometimes people call with pills in hand and are actively considering ending their lives,” Colluccio said. “There are people who have called and said, if you did not pick up, I’d have killed myself.”

He says that’s why having a national network of call centers works so well. There are more than 200 call centers like this one across the country. Calls are tied to area codes. If nobody picks up locally, the call gets kicked to somewhere else.

The promise is to always have someone pick up the phone.

Strained resources for in-person help

In some places, like Bucks County, there are options for callers who need more help than counselors can offer on the phone. Colluccio says he can even dispatch a mobile crew of mental health workers to visit someone at their home.

But that’s not the case everywhere. In Hanover, a small town a few hours west, the 988 call center doesn’t have that option.

Jayne Wildasin runs that center and says workers sometimes have to put down their headsets, get in their cars and go meet with people sometimes as far as an hour away.

“So right now if there’s a crisis at someone’s house we could potentially go there,” Wildasin says.

In rural Centre County, the local 988 call center relies on volunteers — mostly college students from Penn State University. Denise Herr McCann runs the operation and says that her team can call in mobile mental health experts, but there need to be more of them.

Plus there’s a gaping need for other mental health professionals to continue helping people once the crisis has passed.

“Sometimes those resources are other counseling services, and they don’t have capacity,” Herr McCann says. “People are calling, and providers are six weeks out if they’re lucky. That’s not any good.”

For decades, suicide prevention call centers have had to scrape together funding from local, state and federal sources. Now with the switch to 988, they have to meet new federal regulations, such as data collecting and licensure requirements, says Julie Dees, who oversees the call center in Bucks County. That all costs money.

“There are increased responsibilities that are being put on the call centers, but there’s really no additional funding being put on that,” Dees says.

It’s an issue around the U.S., according to a recent analysis from The Pew Charitable Trusts. The group notes that states are largely left to foot the bill for the change to 988 — and many of the call centers doing the actual work have been underfunded for years. It recommends that state policymakers evaluate funding needs to ensure that crisis services connected to 988 will be sustainable.

The Biden administration has dedicated $432 million toward building the capacity of local and backup call centers and providing associated services. But the expectation is that states will come up with the main funding streams.

The 2020 law enacting the 988 number also allows states to pass legislation to add a small fee to cell phone bills as a permanent source of funds for 988 and associated mental health services. So far, only four states have done so, and only two more have proposed legislation.

Pennsylvania is not one of those states, and doesn’t have any other funding plan implemented. That worries Kevin Boozel, who heads the County Commissioners Association of Pennsylvania.

“This is life or death,” Boozel says. “And you can’t halfway do it.”

He pointed out that Pennsylvania has decided to hold back on publicizing the new 988 number until next year. The fear is that too many calls could flood the system, and counties need more time to set up funding, hire workers and build capacity for things like those mobile crisis teams.

Challenges aside, In Centre County, Herr McCann emphasizes that calling the hotline works. In most cases, just talking with someone is enough to defuse a crisis.

“When they have someone who is empathetic and who listens, that connection helps them,” she said. That lets people know that “it isn’t hopeless. There is hope out there. There is help out there.”

Vaccine maker Moderna announced Friday that it’s suing rival drugmakers Pfizer and BioNtech for patent infringement. The lawsuit alleges the two companies used certain key features of technology Moderna developed to make their COVID-19 vaccine. It argues that Pfizer and BioNtech’s vaccine infringes patents Moderna filed between 2010 and 2016 for its messenger RNA or mRNA technology.

All three companies’ COVID-19 vaccines used mRNA technology which is a new way to make vaccines. In the past, vaccines were generally made using parts of a virus, or inactivated virus, to stimulate an immune response. With mRNA technology, the vaccine uses messenger RNA created in a lab to send genetic instructions that teach our cells to make a protein or part of a protein that triggers an immune response.

In October 2020, Moderna pledged not to enforce its COVID-19 related patents while the pandemic was ongoing, according to a statement from the company. In March this year, it said it will stick to its commitment not to enforce its COVID-19 related patents in low and middle-income countries, but expects rival companies like Pfizer to respect its intellectual property.

Moderna is not seeking to remove the Pfizer and BioNTech vaccine from the market, but is seeking monetary damages.

Moderna is filing the lawsuits against Pfizer and BioNTech in the U.S. District Court in Massachusetts and the Regional Court of Düsseldorf in Germany.

A Pfizer spokesperson said in a statement the company has not yet fully reviewed the complaint but it is “confident in our intellectual property supporting the Pfizer/BioNTech vaccine and will vigorously defend against the allegations of the lawsuit.”

More than three months into the U.S. monkeypox outbreak, there’s a new – and welcome – phrase coming from the lips of health officials who are steering the country’s response: cautious optimism.

The change in tone reflects early signs that rates of new infections are slowing in some of the major cities where the virus arrived early and spread quickly, in particular New York City, Chicago, and San Francisco.

Federal officials warn it’s still too soon to make pronouncements about the country turning a corner. Still the slowdown in some parts of the U.S. – coupled with data about how those at highest risk are protecting themselves and getting vaccinated – are promising signs.

“Our numbers are still increasing, [but] the rate of rise is lower,” Dr. Rochelle Walensky, director of the Centers for Disease Control and Prevention, told reporters on Friday. “We’re really hopeful that many of our harm reduction messages and our vaccines are getting out there and working.”

Reported case numbers have been trending down since mid August, based on an NPR analysis of data the CDC released Wednesday. Overall, there’s been around a 25% drop in the 7-day average of new cases over the past two weeks.

However, health officials caution that lags in data reporting can offer an incomplete picture of the outbreak in recent weeks, making it hard to know if cases have truly peaked.

The decline in parts of the U.S. mirrors what’s already being seen in some European countries, where the virus was detected a few weeks earlier. In both the U.K. and Germany, daily case counts have steadily dropped since late July. In several other countries, including the Netherlands and Italy, the number of new cases have plateaued.

Cases slow down in big cities

In New York City – one of the epicenters of the outbreak – the number of new people being infected has dropped 40% over the past month. San Francisco health officials are also seeing a decline in the rate of new cases.

“I’m cautiously optimistic,” says Dr. Susan Philip, health officer for the city and county of San Francisco. “We know, though, it’s going to take a lot of work and effort to sustain that downward curve and to make sure that cases continue to go down.”

The picture is also improving in other cities like Los Angeles, Houston and Chicago where local health leaders say there are indications that infections are leveling off.

Key metrics – such as the average number of cases and the time it takes for cases to double – have decreased over the past couple of weeks, says Janna Kerins, medical director at the Chicago Department of Public Health. “I’m not sure we’re ready to say this outbreak is truly ending,” Kerins says, “But all of those things are encouraging.”

The changes also track with modeling released this week that suggests the national outbreak is on the decline.

“We are seeing signs of a substantial slowdown and the forecasts suggest that this is going to go in the right direction,” at least over the next four weeks, says Gerardo Chowell-Puente, professor of epidemiology and biostatistics at the Georgia State University, who’s modeling the monkeypox outbreak

Changes in behavior drive the decline

Given the size and diversity of the U.S., there’s still considerable uncertainty on how the outbreak will play out in different parts of the country, but infectious disease experts largely attribute the slowdown to efforts to change behavior among gay, bisexual and other men who have sex with men – a group that accounts for the vast majority of cases.

“Most of us in public health who work on this disease are quite confident that the majority of the reduction is due to change in behavior,” says Dr. Jay Varma, director of the Cornell Center for Pandemic Prevention and Response at Weill Cornell Medicine.

More than 94% of monkeypox cases in the U.S. are associated with sexual activity. And on Friday, CDC officials highlighted new data showing that gay and queer communities are modifying their sexual behaviors in response to messaging around monkeypox.

In one online survey, about 50% of respondents said they had reduced “their number of sexual partners, one-time sexual encounters [or] use of dating apps because of the monkeypox outbreak.” An accompanying modeling study released by the CDC showed that a “40% reduction in one-time sexual partnership might delay the spread of monkeypox and reduce the percentage of people infected” by up to about 30%.

“What this means is that the LGBTQIA+ people are doing things that are actually reducing their risk, and it’s working,” said Dr. Demetre Daskalakis, White House monkeypox response deputy coordinator, at a press briefing Friday.

It’s not entirely surprising that the virus appears to be slowing down in the U.S. as it has in Europe, says Dr. Jeffrey Klausner, a professor of medicine and infectious diseases, population and public health sciences at the Keck School of Medicine at the University of Southern California.

“Most of the cities will see a decline in cases – that decline may not be as fast or as steep as the ascent,” says Klausner.

Klausner notes that monkeypox has stayed mostly within certain relatively small sexual networks – that makes it harder for the virus to maintain momentum as vaccination increases, people build up immunity from infection and those at highest risk change their behavior.

“People who raised concerns about the spread of infection on college campuses and daycares and other kinds of settings where there’s close personal contact, at this point, that hasn’t occurred,” he says.

Uncertainty remains

But other experts are not as sanguine about the trajectory of the outbreak – at least not yet.

“It’s great to see some declines,” says Anne Rimoin, an epidemiologist at UCLA who has studied monkeypox for years. “But if the downward trend is due to changes in behavior and vaccinations, it’s not clear how long behavioral changes can be sustained, and how well the vaccinations actually work to prevent infections.”

Health officials are urging members of affected communities to keep taking precautions to slow the spread of monkeypox.

“Let me be clear,” Daskalakis said Friday. “The advice about how to reduce risk for monkeypox exposure is for now, not forever, and is an important part of our public health and community response as we urgently surge vaccinations to control this outbreak.”

Still, there isn’t robust real world data on how well the monkeypox vaccine – approved by the Food and Drug Administration in 2019 – protects against infection and transmission. Further complicating the picture is that a shortage of vaccine has led the Biden administration to pursue a new strategy of offering the shots intradermally in order to stretch the supply.

“The laboratory data that we have on the vaccine suggests that it’s going to be very effective in humans,” says Varma. “But what we know in medicine is that until we see what happens in the real world, we never know for sure.”

NPR’s Michaeleen Doucleff contributed to this report.

As life-preserving medical technology advanced in the second half of the 20th century, doctors and families were faced with a thorny decision, one with weighty legal and moral implications: How should we define when life ends? Cardiopulmonary bypass machines could keep the blood pumping and ventilators could maintain breathing long after a patient’s natural ability to perform those vital functions had ceased.

After decades of deliberations involving physicians, bioethicists, attorneys, and theologians, a U.S. presidential commission in 1981 settled on a scientifically derived dividing line between life and death that has endured, more or less, ever since: A person was considered dead when the entire brain — including the brainstem, its most primitive portion — was no longer functioning, even if other vital functions could be maintained indefinitely through artificial life support.

In the decades since, the committee’s criteria have served as a foundation for laws in most states adopting brain death as a standard for legal death.

Now, with the overturning of Roe v. Wade and dozens of states rushing to impose abortion restrictions, American society is engaged in a chaotic race to define the other pole of human existence: When exactly does human life begin? At conception, the hint of a heartbeat, a first breath, the ability to survive outside the womb with the help of the latest technology?

A legal and political maelstrom

That we’ve been able to devise and apply uniform clinical standards for when life ends, but not when it begins, is due largely to the legal and political maelstrom around abortion.

And in the two months since the U.S. Supreme Court issued its opinion in Dobbs v. Jackson Women’s Health Organization, eliminating a long-standing federal right to abortion, state legislators are eagerly bounding into that void, looking to codify into law assorted definitions of life that carry profound repercussions for abortion rights, birth control, and assisted reproduction, as well as civil and criminal law.

“The court said that when life begins is up to whoever is running your state — whether they are wrong or not, or you agree with them or not,” said Mary Ziegler, a law professor at the University of California-Davis who has written several books on the history of abortion.

Unlike the debate over death, which delved into exquisite medical and scientific detail, the legislative scramble to determine when life’s building blocks reach a threshold that warrants government protection as human life has generally ignored the input of mainstream medical professionals.

Instead, red states across much of the South and portions of the Midwest are adopting language drafted by elected officials that is informed by conservative Christian doctrine, often with little scientific underpinning.

A handful of Republican-led states, including Arkansas, Kentucky, Missouri, and Oklahoma, have passed laws declaring that life begins at fertilization, a contention that opens the door to a host of pregnancy-related litigation. This includes wrongful death lawsuits brought on behalf of the estate of an embryo by disgruntled ex-partners against physicians and women who end a pregnancy or even miscarry. (One such lawsuit is underway in Arizona. Another reached the Alabama Supreme Court.)

In Kentucky, the law outlawing abortion uses morally explosive terms to define pregnancy as “the human female reproductive condition of having a living unborn human being within her body throughout the entire embryonic and fetal stages of the unborn child from fertilization to full gestation and childbirth.”

Several other states, including Georgia, have adopted measures equating life with the point at which an embryo’s nascent cardiac activity can be detected by an ultrasound, at around six weeks of gestation. Many such laws mischaracterize the flickering electrical impulses detectible at that stage as a heartbeat, including in Georgia, whose Department of Revenue recently announced that “any unborn child with a detectable human heartbeat” can be claimed as a dependent.

Defining the role of government in life and death

The Supreme Court’s 1973 decision in Roe v. Wade that established a constitutional right to abortion did not define a moment when life begins. The opinion, written by Justice Harry Blackmun, observed that the Constitution does not provide a definition of “person,” though it extends protections to those born or naturalized in the U.S. The court majority made note of the many disparate views among religions and scientists on when life begins, and concluded it was not up to the states to adopt one theory of life.

Instead, Roe created a framework intended to balance a pregnant woman’s right to make decisions about her body with a public interest in protecting potential human life. That decision and a key ruling that followed generally recognized a woman’s right to abortion up to the point medical professionals judge a fetus viable to survive outside the uterus, at about 24 weeks of gestation.

In decisively overturning Roe in June, the Supreme Court’s conservative majority drew on legal arguments that have shaped another contentious end-of-life issue. The legal standard employed in Dobbs — that there is no right to abortion in the federal Constitution and that states can decide on their own — is the same rationale used in 1997 when the Supreme Court said terminally ill people did not have a constitutional right to medically assisted death. That decision, Washington v. Glucksberg, is mentioned 15 times in the majority opinion for Dobbs and a concurrence by Justice Clarence Thomas.

Often, the same groups that have led the fight to outlaw abortion have also challenged medical aid-in-dying laws. Even after Dobbs, so-called right-to-die laws remain far less common than those codifying state abortion rights. Ten states allow physicians to prescribe lethal doses of medicine for terminally ill patients. Doctors are still prohibited from administering the drugs.

James Bopp, general counsel for the National Right to Life Committee who has been central to the efforts to outlaw abortion, said that both abortion and medically assisted death, which he refers to as physician-assisted suicide, endanger society.

“Every individual human life has inherent value and is sacred,” said Bopp. “The government has the duty to protect that life.”

Both issues raise profound societal questions: Can the government keep a patient on life support against his wishes, or force a woman to give birth? Can states bar their own residents from going to other states to end a pregnancy, or prohibit out-of-state patients from coming in to seek medically assisted death? And who gets to decide, particularly if the answer imposes a singular religious viewpoint?

A philosophical quandary

Just as there are legal implications that flow from determining a person’s death, from organ donation to inheritance, the implied rights held by a legally recognized zygote are potentially vast. Will death certificates be issued for every lost pregnancy? Will miscarriages be investigated? When will Social Security numbers be issued? How will census counts be tallied and congressional districts drawn?

Medical professionals and bioethicists caution that both the beginning and end of life are complicated biological processes that are not defined by a single identifiable moment — and are ill suited to the political arena.

“Unfortunately, biological occurrences are not events, they are processes,” said David Magnus, director of the Stanford Center for Biomedical Ethics.

Moreover, asking doctors “What is life?” or “What is death?” may miss the point, said Magnus: “Medicine can answer the question ‘When does a biological organism cease to exist?’ But they can’t answer the question ‘When does a person begin or end?’ because those are metaphysical issues.”

Ben Sarbey, a doctoral candidate in Duke University’s department of philosophy who studies medical ethics, echoed that perspective, recounting the Paradox of the Heap, a thought experiment that involves placing grains of sand one on top of the next. The philosophical quandary is this: At what point do those grains of sand become something more — a heap?

“We’re going to have a rough time placing a dividing line that this counts as a person and this does not count as a person,” he said. “Many things count as life — a sperm counts as life, a person in a persistent vegetative state counts as life — but does that constitute a person that we should be protecting?”

Even as debate over the court’s abortion decision percolates, the 1981 federal statute that grew out of the presidential committee’s findings, the Uniform Determination of Death Act, is also under review. This year, the Uniform Law Commission, a nonpartisan group of legal experts that drafts laws intended for adoption in multiple states, has taken up the work to revisit the definition of death.

The group will consider sharpening the medical standards for brain death in light of advances in the understanding of brain function. And they will look to address lingering questions raised in recent years as families and religious groups have waged heated legal battles over terminating artificial life support for patients with no brain wave activity.

Bopp, with the National Right to Life Committee, is among those serving on advisory panels for the effort, along with an array of doctors, philosophers, and medical ethicists. The concept of “personhood” that infuses the anti-abortion movement’s broader push for fetal rights is expected to be an underlying topic, albeit in mirror image: When does a life form cease being a person?

Magnus, who is also serving on an advisory panel, has no doubt the commission will reach a consensus, a sober resolution rooted in science. What’s less clear, he said, is whether in today’s political environment that updated definition will hold the same sway, an enduring legal standard embraced across states.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. It is an editorially independent operating program of KFF (Kaiser Family Foundation).

Google will clearly label healthcare facilities that provide abortions in Search and Maps to reduce confusion among users looking for the procedure.

The change comes months after Congressional Democrats pushed the tech giant to better differentiate between abortion clinics and crisis pregnancy centers, which try to dissuade people from seeking abortions and may not offer accurate medical information. 

As part of the update, Google will label facilities that are verified to offer abortions with “provides abortions” in results, while other locations will say “might not provide abortions.” 

“When someone in the US searches for health care providers that provide abortions — for example, using the query ‘abortion clinics near me’ — the Local Search results box will display facilities that have been verified to provide abortions,” Mark Isakowitz, Google vice president of government affairs and public policy for the U.S. and Canada, wrote in a response letter to Sen. Mark Warner and Rep. Elissa Slotkin. 

“People will be able to broaden their search to show other relevant listings (including from organizations that do not provide abortions).”

WHY IT MATTERS

It’s not uncommon for patients looking for abortion services to find misleading information when searching online. According to a Bloomberg News investigation published earlier this month, people seeking abortion providers are “routinely” directed to crisis pregnancy centers on Google Maps. 

Research by the Center for Countering Digital Hate earlier this summer found one in 10 Google search results for abortions in states with trigger laws led to crisis pregnancy centers.

Google’s label update comes just days after review site Yelp announced it would flag crisis pregnancy center listings to distinguish them from clinics and healthcare facilities that offer abortions. 

In the wake of the Dobbs decision overturning Roe v. Wade, privacy experts have raised concerns about how personal data could be used to determine if a user sought an abortion in states where the procedure is now illegal.

In July, Google said it would automatically delete location history when users visit sensitive places like abortion clinics. Period tracking apps, which analyses have noted often share data with third parties, rushed to put out statements about privacy after the Supreme Court decision. Flo launched an “anonymous mode” it said would allow people to use the app without personal email, name and technical identifiers.