The Morning Meeting with Al Tompkins is a daily Poynter briefing of story ideas worth considering and more timely context for journalists, written by senior faculty Al Tompkins. Sign up here to have it delivered to your inbox every weekday morning.
A federal judge in Texas struck down a key component of the Affordable Care Act that provides free preventative care for cancer screenings, mammograms, colonoscopies and a wide range of other preventative tests and drugs. It had been announced that the ruling was coming but it was not clear that the ruling would apply nationwide until Thursday.
The ruling, from Judge Reed O’Connor of the U.S. District Court for the Northern District of Texas, says insurance companies and employers no longer have to cover the cost of preventative and cancer screenings and HIV drugs. Preventive services also include immunizations, behavioral counseling and medications that can prevent the development or worsening of diseases and health conditions.
O’Connor has swiped at the ACA before. In fact, he struck down the whole act in 2018 before the Supreme Court overturned that ruling.
While this case makes its way through the appeals process, insurance companies may impose deductibles and copays on 100 services that were free under the ACA.
The American Medical Association is among 60 leading medical organizations that condemned the lawsuit.
Here is a sample of the screening tests and other preventative services that the ACA required insurance policies cover 100% may now choose not to fully cover:
- Alcohol, tobacco and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Blood pressure screening
- Breast cancer genetic test counseling for women at higher risk
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.” Learn more about contraceptive coverage.
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Cholesterol screening for adults of certain ages or at higher risk
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Domestic and interpersonal violence screening and counseling for all women
- Immunizations for adults and children
- Lead screening for children at risk of exposure
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection prevention counseling for adults at higher risk
A complete list of the preventative services that were free to the patient under ACA but now do not have to be covered by insurance companies and employers:
The list of 100 or so tests and screenings that the ACA mandated as free to the patient was drawn up by the U.S. Preventative Services Task Force, made up of medical professionals of various kinds. The judge said since the task force was neither appointed by a president nor confirmed by the Senate, its rules were not binding.
The judge’s ruling about HIV testing had a different premise. That requirement, he said, violated the Religious Freedom Restoration Act by forcing the plaintiff, Dr. Steven Hotze, to pay for insurance that covers HIV prevention drugs. Hotze argued HIV drugs, known as PrEP, promote homosexual behavior that conflicts with his faith and personal values.
Hotze is high-profile in Texas Republican politics. Among his recent fights was the defeat of proposed nondiscrimination protections for gay and transgender people in Houston. He also pushed for a law mandating that public school students use only the bathroom of the sex listed on their birth certificate. He is described in the lawsuit as operating Braidwood Management “according to Christian principles and teaching.”
In the Texas lawsuit, the judge said that some of the plaintiffs wanted the option to purchase health insurance that “excludes or limits coverage of PrEP drugs, contraception, the HPV vaccine, and the screenings and behavioral counseling for STDs and drug use. They say neither they nor their families require such preventive care. They also claim that compulsory coverage for those services violates their religious beliefs by making them complicit in facilitating homosexual behavior, drug use, and sexual activity outside of marriage between one man and one woman.” Other plaintiffs said they did not want to pay for such coverage for employees.
In the last dozen years, the ACA has survived more than 2,000 legal challenges in state and federal courts.
Dive deeper:
- See who is on the US Preventative Services Task Force
- Read the ruling
Nearly half of all state and local public health employees left their jobs in 5 years
We came to understand the vital nature of public health workers during the pandemic. But almost half of all public health workers left their jobs between 2017 and 2021, and the pandemic made the situation worse. 75% of workers under age 35 quit their jobs. That is three out of four young public health workers.
(Governing.com)
America needs at least 80,000 public health employees to even provide a minimally acceptable level of services.
Governing.com, a website that alerts local government officials about emerging issues, draws its reporting from research published by J.P. Leider, a senior fellow at the University of Minnesota School of Public Health.
Most departures from leadership positions are the result of political pressures and the inability to give sound public health advice without being questioned by elected officials, says Lori Tremmel Freeman, chief executive officer for the National Association of County and City Health Officials (NACCHO). Those who have stayed on the job are managing workers burned out by overwork, harassment and threats.
“None of what we are seeing is necessarily surprising,” Freeman says. She’s especially concerned about small health departments that serve populations of 50,000 or less. They make up two-thirds of the sector and have unique resource problems.
In some cases, pushback against public health is being further fueled by laws limiting public health authority, or candidates seeking city council or county executive positions to act on their perceptions of public health “overreach” during the pandemic.
Where COVID hit hardest; a statistical retrospective
If you asked me what states were hit hardest by COVID-19, I would, off the top of my head, say Florida, New York and California. And for sure, in pure numbers, that would be about right because they are population centers. But when you calculate the number of cases compared to population, as a new report for The Lancet does, the results show some Southwestern states led the way.
- The lowest infection rates were in Hawaii (147 deaths per 100,000) and New Hampshire.
- The highest infection rates were in Arizona (581 per 100,000), Washington, D.C., (526 per 100,000) and New Mexico (521 per 100,000).
- States with lower poverty rates had lower COVID-19 rates.
- States with higher rates of education had lower COVID-19 rates.
- States in which people expressed “interpersonal trust,” which translated into people who were willing to trust medical advice and get vaccinated, had lower COVID-19 rates. The analysis looked at the political affiliations of state governors and found no association between the governors’ political affiliation and states’ death rates.
I am going to point out that the Bill & Melinda Gates Foundation helped fund this study because, without a doubt, conspiracy nuts will say weird stuff about Gates and COVID-19 and vaccines and UFOs and Bigfoot.
Autism rates are significantly higher. But why?
The Centers for Disease Control and Prevention just released data showing the rate of children with autism or autism spectrum disorder (or ASD) is higher than experts previously thought and that nonwhite children have a higher autism rate.
This research shows one in 35 8-year-olds has been diagnosed with autism. That is a significant increase from the 2021 estimate of 1 in 44, which was a big jump from 1 in 110 in 2006.
That is the “what” of the story, but we do not know the “why.” Undoubtedly, cases of autism have risen in recent years, but it is becoming clearer that the rise is mostly linked to better diagnostic work.
The main reason we are finding more autism is simple: Clinicians are getting better at spotting what was always there. There is no simple test for autism, so diagnosing it requires substantial training in observational techniques. As a result, diagnosis can vary significantly depending on the population and the competence of clinicians. The CDC reports significant variations in autism rates from state to state and even from one school district to another. Yet there is little biological evidence to explain this. In another example of the variation, prior reports found more autism in white children.
(CDC)
For 2020:
- One in 36 children aged 8 years (approximately 4% of boys and 1% of girls) was estimated to have ASD.
- For the first time among children aged 8 years, the prevalence of ASD was lower among White children than among other racial and ethnic groups, reversing the direction of racial and ethnic differences in ASD prevalence observed in the past.
- Black children with ASD were still more likely than White children with ASD to have a co-occurring intellectual disability.
Here is more of the fine detail, which helps us to understand that while white children once were diagnosed with ASD at a higher rate than other children, better diagnostic work identifies ASD cases in racial and ethnic minorities that existed all along but went unrecognized:
During the past two decades, ASD prevalence estimates of children aged 8 years from The Autism and Developmental Disabilities Monitoring (ADDM) Network have increased markedly, from 6.7 (one in 150) per 1,000 in 2000 to 23.0 (one in 44) in 2018.
In addition, overall ASD prevalence among White children was 50% higher than among Black or African American (Black) or Hispanic children in earlier years. (Persons of Hispanic origin might be of any race but are categorized as Hispanic; all racial groups are non-Hispanic).
These gaps narrowed over time until ASD prevalence among Black and Hispanic matched prevalence among White children for the first time in 2016 and 2018, respectively.
These patterns have largely been interpreted as improvements in more equitable identification of ASD, particularly for children in groups that have less access or face greater barriers in obtaining services (including diagnostic evaluations). However, consistent disparities for co-occurring intellectual disability exist because among all children with ASD, Black children have the largest proportion identified with intellectual disability.
Stat puts the “so what” front and center by reminding us that identifying autism is important to providing people with the support they need to live with their diagnosis that will last a lifetime:
Most autistics report bullying not only from students but also from therapists and educators. It should not surprise anyone that autistics have poor graduation rates. In adulthood, autistics face under/unemployment and inadequate assistance from rehabilitation agencies.
Many autistics of color end up in the school-to-prison pipeline instead of receiving an appropriate diagnosis and the ensuing understanding and essential services. Adults live under pressure to conform to a world that they may not understand, and that does not understand them.
Even with proper diagnosis, anxiety, depression, and suicidal ideation are constant threats. In the medical domain, autistic people are more likely to experience unrelieved suffering from intestinal distress, epilepsy, and other conditions. Sometimes this is a result of communication barriers, whether because someone is nonspeaking or is unable to make consistent use of language. Other autistic vulnerabilities have genetic or idiopathic causes. Whatever the reasons, too many autistics die early from preventable causes.
Autism does not go away, as evidenced by the numbers of adults now getting diagnosed in their 50s, 60s, and 70s. In fact, the most successful autistics (by neurotypical standards) succeed not by outgrowing their condition but by growing into it and learning to use strategies to achieve.
By the way, pay attention to who authored the thoughtful Stat report about the new CDC data. The author is John Elder Robison, “an autistic adult and the neurodiversity scholar at the College of William & Mary and neurodiversity adviser to Landmark College and the Lawrence Livermore National Lab.” That alone may be a perception and marginalization buster.
People are no longer ‘fleeing cities,’ if they ever really did
We heard a lot of evidence during the pandemic that people were leaving cities for suburbs or even farther out of town. The newest Census Bureau data shows city populations are growing again. You can see it in the data from New York and Dallas, and from Georgia, Florida and North Carolina.
(Census.gov)
College towns are seeing the most growth as students come back to campus full time.
A bald eagle thinks he is hatching an egg. The yolk is on him.
A bald eagle named Murphy is just trying to be a responsible father by tending to what he seems to think is his progeny. But he is sitting on a rock.
(Facebook/Wild Bird Sanctuary)
The Wild Bird Sanctuary where Murphy lives is trying to soothe concerns, explaining that sitting on eggs is not all it is cracked up to be:
“Murphy does not need a real egg to feel accomplished,” the St. Louis-area sanctuary said. “He’s quite content with his rock and VERY protective of it! After his spring hormones have run their course, he will get bored and move on to other activities.”
Asked how he was feeling, Murphy said he was egg-hausted.
My last column
This is the last installment of about 12 years of Morning Meeting columns before I retire. Thank you for reading.
To my journalist friends around the world, thank you for doing what you do.
Take better care of yourself.
