First responders work on a victim of an apparent overdose in Albuquerque, N.M., in August. Despite an encouraging national decrease in overdoses, deaths are still rising in many Western states (Tim Henderson/Stateline).

Despite an encouraging national dip in the past year, overdose deaths are still on the rise in many Western states as the epicenter of the nation’s continuing crisis shifts toward the Pacific Coast, where deadly fentanyl and also methamphetamine are finding more victims.

Overdose deaths remain sharply higher since 2019. Many states are working on “harm reduction” strategies that stress cooperation with people who use drugs; in some cases, states are getting tougher on prosecutions, with murder charges for dealers.

Alaska, Nevada, Washington and Oregon have moved into the top 10 for rate of overdose deaths since 2019, according to a Stateline analysis of federal Centers for Disease Control and Prevention data. Meanwhile the biggest one-year improvements were in Nebraska (down 30%), North Carolina (down 23%), and Vermont, Ohio and Pennsylvania (all down 19%).

The spread of fentanyl, a synthetic opioid that can cause overdose and death even in tiny amounts, explains much of the east-to-west movement in the number of deaths, said Daliah Heller, vice president of overdose prevention program at Vital Strategies, an international advocacy group that works on strengthening public health.

“Fentanyl really came in through the traditional drug markets in the Northeast, but you can see this steady movement westward,” Heller said. “So now we’re seeing overdoses going up on the West Coast while they’re going down dramatically on the East Coast.”

The provisional CDC data estimates drug overdose deaths in the year ending with April 2024, and nationally they decreased by 10%, with more than 11,000 fewer deaths than the year before. But they’re still rising in 10 states and the District of Columbia, including 42% in Alaska, 22% in Oregon, 18% in Nevada and 14% in Washington state. Deaths climbed by almost 1,300 in those states and others with more modest increases: Colorado, Utah and Hawaii.

Experts are still debating why some Eastern states hit early in the overdose crisis are seeing improvements.

“There’s some kind of improvement spreading from east to west and we don’t know exactly what it is yet. Everybody sees their little piece of the elephant,” said Nabarun Dasgupta, a scientist specializing in opioid disorder and overdose at the University of North Carolina’s Injury Prevention Research Center.

In North Carolina and other states with recent improvements, “it feels like we finally got a lid on the pot, but the pot is still boiling over. Things aren’t really cooling down,” Dasgupta said.

It could be a result of better acceptance of harm reduction policies to help those who use drugs, including no-questions-asked testing of street drugs and providing naloxone to counteract overdoses. Or users may simply be getting more wary of fentanyl and its dangers and unpleasant side effects, Dasgupta said.

“Fentanyl is very potent, but potency isn’t the only thing. Otherwise we’d all be drinking the highest proof IPAs (India pale ales),” Dasgupta said.

Alaska now has the nation’s second-highest rate of drug overdose deaths, about 53 per 100,000 population, behind only West Virginia (73 per 100,000). Other Western states that are now in the top 10: Nevada (47 per 100,000), Washington state (46 per 100,000) and Oregon (45 per 100,000).

The CDC data shows Alaska had the largest increase from 2023 — up 42%, to 390 deaths. Republican Gov. Mike Dunleavy in August 2023 proposed legislation making fentanyl dealers subject to murder charges in overdose death cases, writing: “Drugs and drug overdoses have had a devastating effect on our state.” The legislation was signed into law this year.

In May, the state kicked off “One Pill Can Kill,” a national awareness campaign warning about the dangers of fentanyl.

Fentanyl, mostly in the form of counterfeit 30 mg oxycodone pills, has become tremendously profitable for smugglers in Alaska who make use of airline passengers and air shipments of other products to get drugs into the state, said state Department of Public Safety spokesperson Austin McDaniel. Pills that sell for less than $1 near the U.S. southern border with Mexico can fetch $20 in Alaska, McDaniel said.

“We want to make the dealers think twice about targeting Alaska,” said Alaska state Rep. Craig Johnson, an Anchorage Republican, who supported the bill signed into law July 12.

Johnson’s 23-year-old nephew died of a fentanyl overdose two years ago. “This is personal. I don’t want other Alaska families to go through what we went through. I hope we never have to use it, because that will mean nobody else died.”

Other state and federal authorities are also trying a more punitive approach to the fentanyl crisis: Under a state program in Wisconsin meant to ferret out suppliers, three people were arrested in September and charged with first-degree reckless homicide in the fentanyl overdose death of a 27-year-old man. In Michigan, two men pleaded guilty this month to federal charges in a mass fentanyl poisoning that led to at least six deaths.

Such punitive approaches can backfire, experts say, if they drive people toward more dangerous solitary drug use — where no one can see an overdose and try to help — and away from programs such as free testing to unearth fentanyl hidden in other drugs.

“It’s sort of nonsensical, like saying you can beat something out of people. People are still going to use drugs,” said Heller, of Vital Strategies. “This should be a call to action to wake up and really invest in a response to drug use as a health issue.”

In Nevada, health authorities in the Las Vegas area are stressing more cooperation with residents who use drugs, increasing naloxone distribution and encouraging people to submit their drug purchases for testing so they’re not surprised by counterfeit heroin, methamphetamine or other drugs that are increasingly cut with cheaper fentanyl, said Jessica Johnson, health education supervisor for the Southern Nevada Health District.

A state office coordinates goals for county naloxone distribution based on factors such as hospital reports of overdoses. More overdoses trigger more naloxone distribution to community centers, clinics, entertainment venues and even vending machines.

One puzzle in Nevada and in other states is that increasingly, overdoses involve a combination of opioids, such as fentanyl, along with stimulants such as methamphetamine. Almost a third of overdoses in Nevada are caused by both being used together, according to a state report based on 2022 data.

It could be that some people seek the “roller coaster of effects using a stimulant like methamphetamine and a depressant like fentanyl or heroin,” Jessica Johnson said, but mostly she hears that unsuspecting users get cocaine or methamphetamine that’s been cut with cheaper fentanyl.

“We get people saying, ‘Oh I don’t need naloxone because I don’t use fentanyl,’ and our team is able to say, ‘Well, our surveillance data actually suggests there might be fentanyl in your methamphetamine’ or whatever it is.”

Nationally, both drugs are increasingly a factor in fatal overdoses: Synthetic opioids such as fentanyl contributed to 68% of overdose deaths in this year’s CDC data, up from 48% in 2019. Stimulants such as methamphetamine were factors in 35% of deaths, up from 20% in 2019.

Heroin and other partly natural opioids, such as oxycodone, have diminished as factors, together accounting for 13% of deaths in the latest data compared with 40% in 2019.

Some experts theorize that the high potency of fentanyl makes those who use drugs want to tweak or balance the effect with methamphetamine. Fentanyl itself is often cut with xylazine, a non-opioid animal tranquilizer — often known as “tranq” — that can cause unpleasant side effects, including extreme sedation and skin lesions, Dasgupta said.

“During the pandemic, there were a lot of reasons why people were using substances more. Now that things are different, people are tired of the adulteration, the sedation, the skin wounds,” Dasgupta said. “People may take lower doses, and that in itself can help lower overdoses.”

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

Michael Bushnell stands near the planned site of a state psychiatric hospital in Kansas City's historic Northeast. Bushnell, a longtime resident of the Scarritt Renaissance neighborhood and former publisher of the Northeast News newspaper, wants the hospital to be built somewhere else and said neighbors were promised a different plan for developing the site (Vaughn Wheat/The Beacon).

Residents in Kansas City’s historic Northeast neighborhood say plans for a state psychiatric hospital on the site of a former housing project and city park clash with plans for revitalizing their community.

They’re losing patience with efforts to base ever more social services near their homes that they fear could make their streets a dumping ground for the city’s problems.

“This will define one of our most important intersections, and I don’t know if defining it this way is healthy,” said Kate Barsotti, an artist and former president of the Columbus Park Community Council. “Is that shallow? Maybe. Could be. But I do understand people feeling sandbagged and disrespected and betrayed.”

Meanwhile, the city, the state and University Health (formerly Truman Medical Center) see the psychiatric facility as an economic boon and a key part of what the region needs to deal with growing mental health demands.

The Missouri Department of Mental Health estimates the hospital could open in late 2027 or early 2028 — if everything moves smoothly. And the U.S. Department of Housing and Urban Development could be a significant stumbling block to the plan.

Serving the courts

The roughly 20-acre parcel eyed for the psychiatric hospital used to be Belvidere Park and Chouteau Courts, a public housing complex. The tract is near the intersection of The Paseo and Independence Avenue.

In June 2020, the Housing Authority of Kansas City, Missouri, finished demolishing the crumbling Chouteau Courts. The demolition came as part of the sweeping Paseo Gateway community revitalization project, funded through a $30 million grant from HUD.

The new psychiatric hospital would be a one-level, 300,000-square-foot building on a triangular parcel between The Paseo to the east and Interstate 35 to the west. The new hospital would have 200 beds and generally serve the western half of the state.

In tandem with the state’s Center for Behavioral Medicine, which is located on Hospital Hill, the new psychiatric hospital would take on a growing statewide backlog of more than 350 criminal defendants languishing in local jails as they await mental health treatment.

Judges have ordered those inmates into the care of the department to see if it can restore their competency to stand trial, but DMH has nowhere to treat those people (with limited exceptions). DMH Director Valerie Huhn said the waiting list could reach 500 people by the end of this year.

The department said about one-fifth of the pending cases fall in the Kansas City region. It already operates 65 competency-restoration beds (intended to get defendants mentally well enough to stand trial) at the Center for Behavioral Medicine. The new hospital would boost that total to 100 beds while those at the existing facility would be repurposed.

University Health would use the other beds for short-term psychiatric treatment generally lasting two weeks or less. Patients would get psychiatric care medication management and referrals to outpatient programs. The health system would reserve 25 of its beds for referrals from the Kansas City Municipal Court or other providers in the city.

University Health would also operate a psychiatric emergency department at the hospital, something law enforcement turns to avoid taking them to a conventional emergency room or jail.

University Health closed its psychiatric emergency department in 2015, but Chief Executive Officer Charlie Shields said it faces fewer regulatory hurdles in operating as part of a psychiatric hospital.

Critically, it lightens the load for the Center for Behavioral Medicine so it can concentrate on long-term care that can average stays of nine years for treating conditions like schizophrenia or bipolar disorder.

A psychiatric emergency room “allows us to catch people before they get to a point of committing a crime, especially in that Jackson County area,” Huhn said, “and then give them … resources so that they don’t commit crimes and have to go through this whole process.”

Huhn and others tout the safety of the proposed new hospital. It will have a perimeter fence. Patient units will be locked. In that way, it will operate like similar state facilities near residential areas in other parts of the state.

Supporters also say the hospital will offer additional training to area medical programs. It will also open more inpatient beds and fix some of the problems created decades ago when mental health care shifted to community-based care while failing to create enough psychiatric support outside institutions.

At the same time, they see the hospital as an economic jump-start to the surrounding area.

Projections include 600-plus health care jobs (from entry-level to physicians and nurses), an annual boost of $60 million to the area economy, and the bump associated with a $300 million construction project.

Overall, the project is “an exceptional idea and way in which we can better utilize our land in a way that would be beneficial for our community more broadly,” said Kansas City Mayor Quinton Lucas. “This shows that this is a new day on Independence, Paseo and lots of streets many Kansas Citians don’t think about enough.”

Choice neighborhoods

Those thoroughfares were in the limelight in September 2015.

HUD Secretary Julian Castro came to town then to announce a federal grant to Kansas City to tear down the Chouteau Courts public housing project and support the Paseo Gateway District. The housing authority relocated the last of the Chouteau Courts residents to seven new developments in June.

Meanwhile, a range of nonprofit and government agencies have been working to revitalize the neighborhood. Plans included a mix of affordable single-family homes and apartments alongside commercial developments and a public space for community events.

Barsotti, the Columbus Park artist, and Michael Bushnell, a longtime resident of the Scarritt Renaissance neighborhood and former publisher of the Northeast News newspaper, fume that the psychiatric hospital will dash those dreams.

What’s more, the psychiatric hospital project comes on the heels of a city plan to establish a low-barrier homeless shelter at Hope Faith Homeless Assistance Campus at 705 Virginia Ave.

“There needs to be a big ‘no.’ Not here. Go somewhere else,” Bushnell said. “We were promised a completely different development for Chouteau Court. … That’s the plan that needs to be followed.”

Shields said he received positive feedback about the psychiatric center from residents who attended a community information meeting held in August. But detractors said that instead of gathering input, the meeting organizers informed attendees about a done deal.

HUD’s role

HUD could throw a wrench into the financial plans for the psychiatric hospital by requiring the housing authority to sell the former Chouteau Courts property for full market value.

The construction plan assumes the state will acquire the property at little or no cost.

Chouteau Courts was appraised at $1.6 million this year. Any potential environmental cleanup costs would be deducted from that value, said housing authority Executive Director Edwin Lowndes.

Lowndes said paperwork could be submitted to HUD in time for a decision from the agency by the end of November.

HUD can approve a sale for less than market value if it decides the deal has a public good, typically more public housing or projects that benefit people living in public housing. Lucas said the groundbreaking could come early next year.

The mayor acknowledged that residents have been frustrated about the start-and-stop nature of various proposals for the neighborhood. But he said such projects are inherently complicated and don’t always follow original plans.

Barsotti said any lack of follow-through breeds disillusionment.

“It’s really hard,” she said, “to tell people to keep engaging with your city government when it doesn’t seem to work, when they can’t trust what they’re told, when they don’t understand what they’re told, or there’s no time to deal with a big change.”

This article first appeared on Beacon: Kansas City and is republished here under a Creative Commons license.

A handful of people opposed to Amendment 3 protested outside the Missouri Supreme Court on Tuesday, Sept. 10, 2024, following a ruling to keep the abortion amendment on the Nov. 5 ballot (Anna Spoerre/Missouri Independent).

The family business that owns the Kansas City Chiefs is one of the biggest funders of a political action committee opposing a proposed amendment to overturn Missouri’s abortion ban. 

Unity Hunt, the business that controls the assets of the late Lamar Hunt, including the Chiefs, in late September donated $300,000 to the Leadership for America PAC. It is currently running ads on several conservative radio stations across the state opposing the abortion-rights amendment, which will appear on the November ballot as Amendment 3. 

Leadership for America is an independent spending PAC created in January. Prior to receiving the donation from Unity Hunt, the PAC had $31,159 on hand.

Along with paying directly for radio ads, Leadership for America has donated $100,000 to Vote “No” on 3, the main opposition group in the Amendment 3 campaign. And on Oct. 3, the PAC donated $100,000 to a PAC called Missouri Leadership Fund, which gave $100,000 to Vote “No” on 3 six days later.

A spokesperson for the team said Friday that the donation came directly from Lamar Hunt Jr., and not from the Chiefs team.

Unity Hunt did not respond to requests for comment.

No one from Leadership for America could be reached for comment. The telephone number given to the Missouri Ethics Commission for treasurer John Royal has been disconnected.

The ads, which began airing across the state on Monday, call Amendment 3 “cleverly-worded to convince you that it only allows abortions until fetal viability.” 

“But it has loopholes that allow for abortions through all nine months of pregnancy,” the ad continues. “Abortion proponents used to say ‘safe, legal and rare.’ But now they want abortion as common as the morning after pill.”

Supporters of the amendment say claims of abortions in the third trimester are misleading, since the legal freedoms around abortion would only apply until fetal viability, which is generally considered to be around 24 weeks, according to the American College of Obstetricians and Gynecologists.

The amendment text would allow the Missouri legislature to regulate abortion after fetal viability with exceptions only to “protect the life, or physical or mental health of the pregnant person.”

Abortion is illegal from the moment of conception in Missouri, with limited exceptions for medical emergencies. There are no exceptions for victims of rape or incest. 

Failed GOP attempt to keep abortion off Missouri ballot could foreshadow fight to come

Leadership for America has spent a little more than $32,000 on the radio ads, which are set to run through Nov. 4. There are no other broadcast ads opposing the amendment.  

Organized efforts against Amendment 3 have been hugely outspent by Missourians for Constitutional Freedom, the committee backing the amendment. The campaign reported spending $7.3 million through June 30 and has purchased more than $8.7 million in television ads since the start of September.

Vote “No” on 3 has not filed a full disclosure report but has amassed $870,000 in donations greater than $5,000 since Aug. 30.

While the content of the Leadership for America ad aligns with most other opposition talking points, the original source of the money behind the ad drew some attention. 

“It is incredibly disappointing to see Unity Hunt spend resources on this campaign to spread lies and continue the fear-mongering surrounding Amendment 3,” said state Rep. Maggie Nurrenbern, a Democrat from Kansas City. 

Nurrenbern, who is running for the 17th Senate District in Clay County, said she was particularly alarmed by the size of the donation from a family she said “has done so much good for Kansas City and the Kansas City area.” 

State Rep. Ashley Aune, also a Democrat from Kansas City, said she wasn’t surprised to see the Hunt family backing an effort to stop abortion.

“But also, it’s disappointing because when you have such a big platform,” Aune said. “Using that platform to sow misinformation is a really irresponsible way to use it.”

In 2020, Lamar Hunt Jr. served as the master of ceremonies at the Kansans for Life annual Valentine’s Day banquet. 

Hunt, an owner of the Chiefs, told the crowd: “I do not think it is a cliché to say we are in a life and death battle for the truth and authentic dignity of the human person.” 

Hunt six years earlier published a blog post to his website contemplating what he observed as cultural shifts away from the “pro-choice” movement, comparing the momentum in the “pro-life” community to the San Francisco 49ers comeback and near-win in the final seconds of the 2013 Super Bowl.

This story was updated at 3:20 p.m. Friday to include a comment from a Kansas City Chiefs spokesperson.

Missourians for Healthy Families and Fair Wages prepare for a press conference in May, 2024 (Annelise Hanshaw/Missouri Independent).

A measure that would guarantee paid sick leave for over 700,000 Missouri workers who currently lack it, as well as gradually raise the minimum wage to $15 per hour, will appear on voters’ ballots next month.

The ballot initiative, called Proposition A, has been backed by various unions and workers’ advocacy groups, social justice and civil rights organizations, over 500 state business owners and others. 

Some business groups, including the state Chamber of Commerce, have opposed it, especially the guaranteed sick leave portion. But thus far there hasn’t been a coordinated opposition campaign. 

The campaign in favor of the measure, called Missourians for Healthy Families and Fair Wages, has raised over $5 million — including from out-of-state groups that don’t disclose their donors— and collected 210,000 signatures to have the issue placed on the statewide ballot.

Most expect the ballot measure to succeed, given polling, national trends with similar ballot measures and the lack of coordinated opposition. Missourians have approved minimum wage increases on the ballot twice before by wide margins. 

“We believe full-time work deserves better than poverty,” said Richard Von Glahn, campaign manager for Missourians for Healthy Families and Fair Wages, “but current minimum wage — that’s what it leads to.” 

The current minimum wage in Missouri is $12.30, which is equivalent to $492 per week, before taxes.

And without sick leave, proponents argue, workers have to choose between their financial and physical wellbeing — going into work sick or losing out on a needed paycheck.

“Everybody gets sick. Everybody has a child or someone they care for that gets sick,” Von Glahn said, “But when there’s an unequal ability to care for yourself or care for your family, that is unjust.”

Businesses would be required to provide one hour of paid sick time for every 30 hours worked, up to five days per year for small businesses and seven days per year for larger businesses. Small businesses are those with fewer than 15 employees.

Some business groups have said the proposal constitutes government overreach in what should be the decisions of business owners.

“A business owner’s ability to set their own workplace policies and procedures is really the bedrock on which our free enterprise system is built,” said Kara Corches, interim president and CEO of the Missouri Chamber of Commerce and Industry. “So this is creating a new mandate for employers in terms of wage as well as paid leave policy, that is really against that principle of ‘let business decide.”

“…We want to make sure that Missouri is the most business friendly state in the nation, and we don’t think that this proposition is sending that message,” Corches added.

Sick leave

The ballot measure would make sick leave guaranteed for 728,000 workers who currently lack it statewide, or over 1 in 3 Missouri workers, according to an analysis from the progressive nonprofit the Missouri Budget Project.

Many of those who lack paid sick leave are the lowest earners.

“Sick days are very common amongst the highest paid workers, you know, executives, those types of positions,” Von Glahn said, “but particularly in some of the lower wage industries — the industries that we’ve been calling essential for a number of years now — construction, retail, food service, nursing home, childcare workers, they lack access to this.”

Employees would be allowed to take the time for mental or physical illness, to take care of a family member, or due to a domestic violence situation, according to the proposition.

Employers could require documentation when a worker takes three or more days off in a row, such as a doctor’s note, but wouldn’t be allowed to require disclosure of detailed health information.

Corches said the paid sick leave part of the measure is what “gives us a little more heartburn, just because it’s so nebulous,” and open to interpretation. She pointed specifically to confusion around provisions that would give employees a civil cause of action to sue if employers break the law, and another provision that prohibits employers from retaliation when workers take leave. 

“Business owners have enough on their plates, just trying to, you know, keep their businesses open, retain and recruit employees, and this nine page new proposition is very complicated and is going to make compliance quite challenging,” Corches said.

If the measure passes in Missouri, the paid sick time provision will kick in on May 1, 2025.

Ray McCarty, CEO of Associated Industries of Missouri, a business advocacy organization, raised concerns that “you will have people that abuse the system,” meaning those who take sick leave who don’t qualify. McCarty said in some cases employers may need proof of the legitimate absence earlier than three days in, or need to ask for more detailed information.

Missouri would join 15 states that require employers to provide paid sick leave. The United States, unlike nearly every other country, lacks federal paid sick leave, so states, as well as cities, have taken the lead. 

In states that have adopted sick leave mandates, employees take, on average, two more sick days a year than prior to the law going into effect, a National Bureau of Economic Research report found.

Studies have found that offering paid sick time can increase workers’ productivity and reduce illness, and generally adds little or nothing to business expenses.

Nebraska and Alaska also have paid sick leave on the ballot this year.

Minimum wage

The ballot measure also would raise the state’s minimum wage to $13.75 next year and $15 in Jan. 2026. 

The increase would affect over 562,000 workers in the state, according to the Missouri Budget Project, or nearly one in every four workers. The minimum wage would be adjusted based on inflation every year after 2026.

McCarty said most members in Associated Industries of Missouri already pay at least $15 hourly, though they may not realize the “whole wage scale will slide up,” meaning raising the minimum wage could have spillover effects on other wages, for businesses to remain competitive. 

He said some employers could go over to Kansas and pay less, so may choose to be based in neighboring states. 

The states neighboring Missouri already have lower minimum wages, except for Illinois, which is $14 per hour. 

A coalition of hundreds of businesspeople in the state have signed on to support the ballot measure, arguing the policies help their bottom line, causing lower employee turnover, increased productivity and better health and safety conditions.

Ballot initiatives to raise the minimum wage are generally likely to succeed, and have previously succeeded in Missouri, amidst legislative inaction or opposition.

Voters approved a minimum-wage hike in 2006, with 75% of the vote, and again in 2018, with 62% of the vote.

Advocates have had success with ballot measures as, for years, Republicans in the legislature have voted against or failed to hear proposals to increase the minimum wage, Von Glahn said. In 2017 the legislature passed a law prohibiting cities from raising the minimum wage beyond that of the state’s, after St. Louis city passed an ordinance to raise the city’s minimum wage.

The federal minimum wage has been stagnant, at $7.25, since 2009. Thirty states, including Missouri, have a minimum wage higher than the federal one.

‘Confident it will pass’

Missourians for Healthy Families and Fair Wages has so far raised over $5 million, according to campaign filings. 

That includes two $1.2 million donations from the D.C.-based Sixteen Thirty Fund, in August and October, a progressive nonprofit that is not required to disclose its donors. Other large donors include Missouri Jobs with Justice Voter Action and the D.C.-based The Fairness Project.

The campaign has purchased over $1.4 million in television ads, slated to begin airing next week, according to Federal Communications Commission filings.

The ballot measure would change the state law but not the constitution, meaning the legislature could overturn it, but that is unlikely, McCarty said. 

“I don’t see any politician in their right mind — if this passes with a high percentage of votes, which we expect it will — I don’t see any politician in their right mind completely repealing the entire law,” he said, citing potential concerns about overturning the will of voters.

Corches said the Chamber is focused on the election and would only “start looking at, is it possible to modify this in the Capitol” if it passes.  

Von Glahn said Prop A will be a test of whether or not the legislature “respects the will of voters.”

The St. Louis University/YouGov poll conducted in August found the ballot measure had a strong backing, with 57% of those surveyed supporting it.

“We feel confident that it will pass next month, but we’re also doing the work,” Von Glahn said. “I mean, we’ve got people out canvassing every day, talking to voters about it.”

The Planned Parenthood clinic in St. Louis on June 24, 2022 (Tessa Weinberg/Missouri Independent).

Three Planned Parenthood clinics in eastern and southern Missouri will shut their doors next month, though the organization’s leaders insist the moves will ultimately expand access to reproductive health care. 

As part of the consolidation effort, Planned Parenthood Great Rivers will be expanding telehealth services and hours at its remaining St. Louis clinics. 

The moves come as the state has successfully implemented legislation cutting Planned Parenthood clinics off from Medicaid funding, though the organization’s leadership says the closures are not related to the new law. 

They are also taking place as Missourians are set to vote on whether to enshrine abortion rights in the state constitution, a decision that could radically expand access to reproductive health care around the state.

Failed GOP attempt to keep abortion off Missouri ballot could foreshadow fight to come

On Nov. 1, the Florissant health center in North St. Louis County and the South Grand Health Center just south of downtown St. Louis will close. 

On Jan. 1, the health center in Joplin will also close. No staff members are being laid off as part of the restructuring, Planned Parenthood said in a press release.

Richard Muniz, interim president and CEO of Planned Parenthood Great Rivers, said patient care can be transferred to other Planned Parenthood locations. He said the goal is to increase virtual care access and get patients in touch with providers sooner, and then into appointments more quickly.

“The operational changes we’re announcing will ensure that we’re here for our patients not just today, tomorrow, but for the next 90 years,” Muniz said in a statement. “Our patients are our top priority, and despite repeated attacks from politicians, our commitment never wavers. We’re going to be here for them no matter what.”

For Joplin patients, transportation will be provided to the Springfield clinic 75 miles away for those who need it. Planned Parenthood will also refer patients to the Pittsburg, Kansas, clinic about 30 miles away that opened earlier this year.

Muniz said the decision on which clinics to close was data-driven. Many Planned Parenthood patients travel to more than one health center, he said, often picking the one with the soonest availability rather than closest locations.

Two of the remaining St. Louis area clinics — the West County location in Manchester and the St. Peters location — will expand services beginning Nov. 1 to include a Title X family planning program for those who are uninsured or underinsured. 

The clinics in St. Peters will begin seeing patients five days a week, including one Saturday a month, and the Central West End clinic, near downtown St. Louis, will increase appointment availability for health needs including STI testing and treatment, cancer screenings and wellness exams. 

Muniz said the changes are meant to “ensure long-term sustainability in the face of repeated attacks from politicians on sexual and reproductive health care — including seven consecutive years of trying to deny reimbursement for the lifesaving services we provide to Missourians who use Medicaid.”

Lawmakers this year passed a bill, which was signed into law by Gov. Mike Parson, ending Medicaid reimbursements to Planned Parenthood. This means clinics won’t be compensated for patients they serve who are on Medicaid. 

Fights over the legislation earlier this year emphasized Missouri’s reproductive health care and contraceptive deserts. 

Planned Parenthood Great Rivers, like Planned Parenthood Great Plains on the western side of the state, has continued seeing patients on Medicaid despite the new law thanks to donor support, Muniz said. A lawsuit filed by Planned Parenthood claiming the new law is unconstitutional is ongoing.

The decision to consolidate had nothing to do directly with the new legislation, Muniz said. Planned Parenthood Great Rivers serves about 9,000 patients a year on Medicaid. 

The main catalysts, he said, were changes to the health care system because of COVID, and increased requests from patients to access care from home via telehealth options. 

“Our mission is to center the needs of our patients at the core of all of our decision-making,” he said. “Which is why we are making necessary service changes to adapt to their needs.” 

Asked if the consolidation was a cost-saving measure, Muniz said the focus was long-term stability for patients.

Missouri’s reproductive rights amendment, which will appear on the ballot as Amendment 3 , was not a consideration in the decision, Muniz said. He declined to say which Missouri Planned Parenthood locations may initially start providing abortion services again if Amendment 3 passes. 

“We expect amendment 3 to pass, and when it does pass, what abortion access will look like in the state of Missouri is going to be dependent on litigation and what restrictions courts will block from remaining in effect,” he said. 

Judge Craig Carter, a Wright County judge serving in Cole County for Missouri's gender-affirming care trial, listens to a nurse practitioner testify on the fourth day of the trial (Annelise Hanshaw/Missouri Independent).

A ruling on Missouri’s restrictions on gender-affirming care is likely to come by the end of the year, with the trial complete and attorneys’ reports due within 30 days.

After a 13-day trial ended last week, Wright County Circuit Court Judge Craig Carter waived closing statements and asked instead for plaintiffs and defendants to submit statements of facts and findings. Both sides presented thick stacks of evidence, with seven approximately five-inch binders sitting on Carter’s bench throughout proceedings.

Without a jury, Carter — who was assigned to preside over the Cole County case — will rule on the constitutionality of the law.

Carter’s questions at the start of the trial sounded like someone becoming familiar with the subject, asking what a nonbinary gender identity means and clarifying definitions.

But in the trial’s final days, his inquiries were more frequent and challenging for witnesses, digging into the arguments and searching for the point in which gender-affirming medication for minors switches from unlawful to lawful.

The trial comes after transgender minors, their families and health care providers challenged the constitutionality of a 2023 law restricting physicians from prescribing gender-affirming medical care to minors. It also bars Missouri Medicaid from covering gender-affirming treatment for adults and restricts prisoners from getting the care in state prisons.

Carter asked many of the questions to the state’s expert witness, Dr. Farr Curlin, a professor at Duke who specializes in medical ethics.

“So tell me your thoughts on the intersection,” Carter asked during Curlin’s testimony last Wednesday. “The state has an interest in preventing people from making life-altering mistakes, and plaintiffs have the right to seek (desired medical care).”

Curlin said the problem lies in children’s inability to consent. Typically, parents consent for their child, whereas a minor’s agreement is labeled assent.

“The norm should be the same norm that is practiced throughout pediatric ethics and it is: Is this intervention in the medical best interest of the child?” Curlin said.

A large piece of the case is whether there is medical consensus on the efficacy of medical transition.

Large medical organizations like the American Academy of Pediatrics, a group founded in 1930 with 67,000 member physicians, support gender-affirming care for minors. Other organizations outside the medical mainstream — like the 700-member American College of Pediatricians which was formed in 2002 — are outspoken against the treatment.

Plaintiffs’ experts reviewed research showing positive effects of medical transition, and people who have benefited from gender-affirming care in Missouri as minors testified. The attorney general’s office, which was defending the law, tried to diminish the testimony of these experts by claiming that because most provide gender-affirming care —either by writing letters of support as a mental health provider or prescribing medication — they financially benefit from ensuring it remains legal. 

Plaintiffs waved off these concerns. 

“Only to the state of Missouri, and without any sense of irony, is actually having experience and expertise a conflict,” Omar Gonzalez-Pagan, an attorney with Lambda Legal, told reporters.

The state’s expert witnesses included physicians who are outspoken about their disapproval of gender-affirming care, though many had never treated a minor for gender dysphoria. During the testimony of Alabama-based plastic surgeon Dr. Patrick Lappert, attorneys showed images of gender-affirming surgeries and detailed the process and risks of infection.

In 2022, a federal court in North Carolina ruled that state health plans excluding gender-affirming care violated the Equal Protection Clause. In that case, the judge tossed out parts of the testimony of  Lappert and Dr. Stephen Levine, who also testified last week as an expert for the state of Missouri.

Tom Bastian, spokesman for the ACLU of Missouri, told The Independent in emailed answers the case’s attorneys oversaw that the state’s argument is not sufficient to justify the law. Specifically, he pointed to what he deemed a lack of expertise among the state’s expert witnesses.

“None of the state’s purported expert witnesses practice in this field, except for one, and the one who does agrees that medical interventions for gender dysphoria can be appropriate for some patients,” Bastian wrote. “Plaintiffs’ doctors, their experts and every major medical organization in the United States all agree that, in certain cases, gender-affirming medical care can be medically necessary to treat gender dysphoria in adolescents and adults.”

Another expert called by the Missouri attorney general’s office last week was John Michael Bailey. He received skepticism from Carter after it was revealed that he believes convicted child molester Jerry Sandusky is innocent. Bailey has been criticized for a retracted research article on gender dysphoria in adolescents and was the subject of an investigation by Northwestern University after he demonstrated a sex toy in an extracurricular lecture.

The Independent sent questions to the attorney general’s office, including asking about criticism of its expert witnesses, but did not receive a response.

Four people who had once identified as transgender but stopped treatment, known as “detransitioners,” also testified last about their regrets. Only one of the four received medical care in Missouri, and he was an adult when he began his transition.

“The adults that were in the room that should have been protecting them failed to do so,” Attorney General Andrew Bailey said in a podcast late last month before the trial began.

The state also introduced academic articles describing the evidence behind gender-affirming care for minors as “too limited,” both in cross-examination and through their witnesses’ testimony.

Carter asked if the law could be peeled back if research showed treatments’ success. The state’s restrictions on puberty blockers and cross-sex hormones for minors is set to expire in August of 2027 — though lawmakers have publicly discussed removing the sunset clause.

“Are you saying the kids don’t have a choice until we get further evidence showing the efficacy of these treatments?” Carter asked Curlin, the Duke medical professor. “If the studies show that this treatment is efficacious, then where do we wind up?”

“It’s not just, is it efficacious?” Curlin said. “Is it efficacious, and is it reliable enough and substantial enough to warrant the risks that these treatments bring?”

“What if the drug companies come out tomorrow and say, ‘You can take this drug, and it is absolutely reversible,” Carter asked.

Curlin said the “treatments are absolutely counter to the well-working of this patient’s health.” The medications and surgeries are not ethical in a body that is functioning well, he said.

The state repeatedly presented talk therapy as an option to treat gender dysphoria, which is distress arising from one’s body not matching gender identity.

Plaintiffs said therapy alone will not treat many cases of gender dysphoria, making medication medically necessary.

On the first day of the trial, a young man testifying under the name John Doe told the court that therapy was not enough for him. His first therapist said he was “going through a phase,” and his dysphoria only worsened.

A second, affirming therapist helped him as he began to dress more like himself at the age of 7, he said. His fear only worsened as puberty approached, and he attributes his thriving social life and success in college to his access to medication.

“It felt like once I started to receive (testosterone) shots, my overall was uphill from there,” he said. “The confidence I gained from having my body reflect who I am and what I was feeling was impactful throughout my entire life.”

Doe’s mother also testified later in the trial.

Carter noted there was “heartfelt testimony on both sides” from parents, asking about the issue of parental rights when the state withholds a type of care from their child. He discussed the Right to Try Act, which allows patients to access experimental medications for life-threatening conditions.

He also looked at the release of the COVID-19 vaccine, which had an accelerated clinical trial phase in order to give the public access sooner. The vaccine could potentially serve as a precedent of giving access to a medication without longitudinal testing.

Carter’s ruling is unlikely to be the last, with similar cases in other states appealing all the way to the U.S. Supreme Court. He noted the likelihood of an appeal, saying he would accept exhibits to add to the case’s file for future courts to look at, though they would not determine his ruling.

A case of bird flu in a Missouri resident is the only diagnosis in the United States this year where the person did not have contact with infected dairy cattle or poultry (Stephen Ausmus/Animal Research Services, USDA).

WASHINGTON — The Centers for Disease Control and Prevention should have results later this month that provide more insight into how a Missouri resident, who hadn’t had any contact with infected animals or food, contracted a case of highly pathogenic avian influenza.

Demetre Daskalakis, director of the National Center for Immunization and Respiratory Diseases at the CDC, said on a call with reporters Friday the agency is working through its investigation of that bird flu case, while providing several more details.

“As we previously reported, CDC would be able to perform partial sequencing of the avian influenza H5 virus from the case in Missouri, despite a nearly undetectable level of viral RNA in the patient sample,” Daskalakis said.

That process is complex and time-consuming, in part because the patient had rather small amounts of the virus in their system when the test was taken.

Another contributing factor, he said, is “that the virus has two potentially important mutations, meaning two amino acid differences, in comparison with the viruses previously characterized during this event that could affect antigenicity.”

Daskalakis explained that antigenicity is when someone is able to produce “a specific immune response, such as creation of specific antibodies.”

Both the mutations and small sample size have presented challenges for the CDC, but the agency expects to announce results of the test later this month after completing the complicated lab process, he said.

Two cases in California

The Missouri case is the only bird flu diagnosis in the United States this year where the person hadn’t had direct contact with infected poultry or dairy cattle.

The remainder of the 16 people diagnosed with H5N1 during this calendar year had direct contact with farm animals, with nine of those cases linked to poultry and six related to dairy cows.

One of those cases was diagnosed in Texas, two in Michigan, two in California just this week and 10 in Colorado.

Public health officials on the call emphasized that the risk to the general public remains low and that several studies undertaken by the Food and Drug Administration show pasteurized dairy products as well as other foods remain safe to eat.

Since February, the CDC has tested more than 50,000 samples that would have “detected Influenza A, H5 or other novel influenza viruses,” Daskalakis said.

The Missouri case was the first case of bird flu detected through that influenza surveillance system, he said.

Public health officials at the state and federal level have been trying to determine how the Missouri patient, who officials are not identifying for their privacy, contracted the virus through a series of “intense interviews,” Daskalakis said.

That is how they learned someone living in the same house had been symptomatic with various gastrointestinal issues at the same time the patient had been ill.

That simultaneous onset of symptoms implied “a common exposure, rather than human-to-human transmission,” Daskalakis said, before reinforcing that the second person never tested positive for the virus and isn’t considered a case of bird flu.

“At the time of the interview, the household contact had also completely recovered and had not been tested for influenza while they were sick,” he said. “To be clear, there is only one case of H5N1 influenza detected in Missouri.”

Because the person living in the same house as the Missouri patient had been symptom-free for more than 10 days when they were interviewed by public health officials, Daskalakis said there was “no utility in testing the contact for acute influenza.”

Instead, officials in Missouri took blood samples from the two people so the CDC could test for “antibodies against H5 to assess for possible infection with this virus,” he said.

A separate investigation was taken at the hospital where the Missouri patient had been diagnosed to see if any health care workers had contracted H5N1.

Out of 118 health care workers who interacted with the patient in some way, 18 had higher-risk interactions before the patient was diagnosed and began using what Daskalakis referred to as “droplet precautions.”

Six of those health care workers later developed respiratory symptoms, though only one of them had symptoms by the time the public health investigation had begun retroactively, he said.

That one person’s PCR test for acute influenza came back negative and the other five health care workers, who had recovered, did not require a PCR test, he said.

“Since exposures could only be assessed retrospectively, Missouri has also obtained blood specimens from these individuals for antibody or serology testing at CDC to search for any evidence to support the unlikely possibility that their symptoms were related to H5 infection resulting from their interaction with the patient,” Daskalakis said. “Despite the low risk, this testing is important to complete the public health investigation of this case.”

The CDC began working on that serology testing in mid-September when it received the samples from Missouri, though the complicated process likely won’t conclude until later in October.

“For serology testing to be conclusive, it needs to be done using a virus that is genetically identical to the one obtained from the human case from Missouri or there is a risk of a false negative test,” Daskalakis said. “Since this H5 virus was not recoverable, we could not grow it because there was not enough for the Missouri specimen.”

The CDC, he explained, has to “create the right virus for the test using reverse genetics to match the one from Missouri, so that we can use it in these serology tests.”

“We realize people, including all of us at CDC, are anxious to see results from this testing,” he said. “CDC is moving at a very accelerated pace while conducting rigorous science to assure the validity of these results.”

Poultry, dairy cases

In addition to human cases, bird flu continues to infect poultry flocks and dairy herds within the United States.

While the poultry industry has had years of experience supplying its workers with personal protective equipment and culling affected farms, the dairy industry has had to figure out how to address the virus this year.

Eric Deeble, deputy under secretary for marketing and regulatory programs at USDA, said on the call Friday that Colorado’s mandatory testing program of bulk milk tanks, which began in July, offered a hopeful case study for ridding farms throughout the country of H5N1.

“Initially, this revealed a significant local prevalence, about 72% of dairies, centered in Weld County,” Deeble said.

But following months of hard work by farmers and public health officials, Colorado has just one dairy herd that’s currently affected by H5N1 out of 86 dairy herds within the state, he said.

“Mandatory surveillance in the state allows for continuous monitoring of herds and helps detect any instances of non-negative results early on, ensuring timely intervention,” Deeble said. “This decrease in Colorado cases, even in the absence of a vaccine, gives us further confidence that H5N1 can be eliminated in the national herd, even in places where we have seen an initial rapid increase in cases.”

Data from the USDA show that during the past month, three dairy herds in Idaho and 53 in California have tested positive for H5N1.

James Larrabee uses a chainsaw to remove limbs from a dead tree at the Veteran Urban Farm in Columbia (Benjamin Zweig/Missourian).

An ultrasound machine sits next to an exam table in an examination room at a women’s health clinic in South Bend, Ind. A recent study shows that there was a spike in the number of women seeking sterilizations to prevent pregnancy in the months after the U.S. Supreme Court’s decision striking down the constitutional right to an abortion (Scott Olson/Getty Images).

In the months after the U.S. Supreme Court struck down the constitutional right to an abortion, there was a spike in the number of women seeking sterilizations to prevent pregnancy, a recent study shows.

Researchers saw a 3% increase in tubal sterilizations per month between July and December 2022 in states with abortion bans, according to the study published in September in JAMA, a journal from the American Medical Association. The Supreme Court struck down Roe v. Wade in June 2022.

The study looked at the commercial health insurance claim records of 1.4 million people from 15 states with abortion bans (Alabama, Arizona, Arkansas, Idaho, Indiana, Kentucky, Mississippi, Missouri, Oklahoma, Tennessee, Texas, Utah, West Virginia, Wisconsin and Wyoming). The study also examined the records of about 1.5 million people living in states with some abortion restrictions and 1.8 million in states where abortion remains legal. The researchers excluded 14 states that didn’t have records available for 2022.

“It’s probably an indication of women [who] wanted to reduce uncertainty and protect themselves,” said lead author Xiao Xu, an associate professor of reproductive sciences at Columbia University. In the first month after the ruling, sterilizations saw a one-time increase across all states included in the study, Xu and her team found. Her team also found continued increases in states that limited abortion to a certain gestational age, but those were not statistically significant.

The researchers compared records for three groups: States with a total or near-total ban on abortion, including states where bans were temporarily blocked; states where laws explicitly recognized abortion rights; and limited states, where abortion was legal up to a certain gestational age.

While the study captures only the early months following the Dobbs ruling that overturned Roe v. Wade, experts say it’s part of an increasing body of evidence that shows a growing urgency for sterilization procedures amid more limited access to abortions, reproductive health care and contraception. Other studies have shown increases in tubal sterilization (commonly known as “getting your tubes tied”) and vasectomy requests and procedures post-Dobbs.

Diana Greene Foster, a professor and research director in reproductive health at the University of California, San Francisco, said the results are not surprising, given the negative repercussions for women who seek to end their pregnancies but are not allowed to do so.

Foster led the landmark Turnaway Study, which for a decade followed women who received abortions and those who were denied abortions. It found that women forced to carry a pregnancy to term experienced financial hardship, health and delivery complications, and were more likely to raise the child alone.

“We have found that women are able to foresee the consequences of carrying an unwanted pregnancy to term,” Foster told Stateline. “The reasons people give for choosing an abortion — insufficient resources, poor relationships, the need to care for existing children — are the same negative outcomes we see when they cannot get an abortion.

“So it is not surprising that some people will respond to the lack of legal abortion by trying to avoid a pregnancy altogether.”

Few doctors and services

States with abortion bans and other restrictions also tend to have large swaths of maternal health care “deserts,” where there are too few OB-GYNs and labor and delivery facilities. That creates greater maternal health risks.

One such state is Georgia, where until a court ruling this week, abortion was banned after six weeks. Dr. LeThenia “Joy” Baker, an OB-GYN in rural Georgia, said she sees patients in their early 20s who have multiple children and are seeking sterilizations to prevent further pregnancies, or who have conditions that make pregnancy dangerous for them. Her state has one of the highest maternal death rates in the nation.

On Monday, a Georgia county judge struck down the state’s six-week abortion ban, meaning that for now, women have access to the procedure up to about 22 weeks of pregnancy. The state is appealing the decision, and it’s expected to eventually be decided by the state Supreme Court.

The county judge’s ruling comes two weeks after ProPublica reported that two women in the state died after they couldn’t access legal in-state abortions and timely medical care for rare complications from abortion pills.

Black and Indigenous women disproportionately experience higher rates of complications, such as preeclampsia and hemorrhage, which contributes to their higher maternal mortality and morbidity rates. Baker said some of her patients say they want to avoid risking another pregnancy because of those previous complications.

“I have had quite a few patients, who were both pregnant and not pregnant, who inquire about sterilization,” she said. “I do think that patients are thinking a lot more about their reproductive life plan now, because there is very little margin.”

Along with the state’s abortion restrictions, Baker said women in her Bible Belt community feel social pressure that can push them toward sterilization.

“It is definitely more socially acceptable to say, ‘I’m going to get my tubes tied or removed,’ than to say, ‘Hey, I want to find abortion care,’” Baker said.

In states where lawmakers have proposed restrictions on contraception, women might feel tubal sterilization to be the most surefire way to prevent pregnancy. Megan Kavanaugh, a contraception researcher at the Guttmacher Institute, a reproductive health policy research center that supports abortion rights, said the research doesn’t say whether women who seek sterilization would have preferred another form of contraception.

“We need to both understand which methods people are using and whether those methods are actually the methods they want to be using,” said Kavanaugh, whose team studied contraceptive access and use in Arizona, Iowa, New Jersey and Wisconsin. “It’s really important to be monitoring both use and preferences in terms of heading towards an ideal where those are aligned.”

Tubal sterilizations can still fail at preventing a pregnancy, Foster said. One recent study noted that up to 5% of patients who underwent a tubal sterilization got pregnant later.

“If people are choosing sterilization who would otherwise pick something less permanent, then that is another very sad outcome of these abortion bans,” she added.

Another recent study, by Jacqueline Ellison, a University of Pittsburgh assistant professor who researches health policy, found that more young patients — both women and men — sought permanent contraceptive procedures in the wake of the Dobbs decision. The study focused on people ages 18 to 30 — the age group most likely to seek an abortion and the ones who previous studies suggest are most likely to experience “sterilization regret,” Ellison said.

A troubled history

The issue also can’t be disentangled from the nation’s history of coercive sterilizations, Ellison and other experts said. In the 1960s and 1970s, federally funded nonconsensual sterilization procedures were performed on Indigenous, Black and Hispanic women, as well as people with disabilities.

“People feeling pressured to undergo permanent contraception and people being forced into using permanent contraception are just two sides of the idea of reproductive oppression in this country,” Ellison said. “They’re just manifested in different ways.”

Medicaid, the joint federal-state health insurance program for low-income people, now has regulations designed to prevent coerced procedures. But the rules can have unintended consequences, said Dr. Sonya Borrero, an internal medicine physician and director of the University of Pittsburgh’s Center for Innovative Research on Gender Health Equity.

The process includes a 30-day waiting period after a patient signs a sterilization procedure consent form, Borrero noted. But pregnant women who want the procedure done right after delivery might not reach the 30-day threshold if they go into early labor, she said. She added that some patients are confused by the form.

Borrero launched a tool called MyDecision/MiDecisión, an English and Spanish web-based tool that walks patients through their tubal ligation decision and dispels misinformation around the permanent procedure.

“The importance and the relevance of it right now is particularly pronounced,” she said.

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

ACLU of Missouri attorney Gillian Wilcox takes notes while a witness testifies in Missouri's gender-affirming care trial in Cole County Circuit Court (Annelise Hanshaw/Missouri Independent).

Missouri’s defense of a state law barring minors from beginning puberty blockers and cross-sex hormones will depend on whether the judge in the case puts stock in expert witnesses touting retracted studies and conspiracy theories about Jerry Sandusky.

Wright County Circuit Court Judge Craig Carter, who is presiding over a lawsuit challenging Missouri’s gender-affirming care restrictions, will have to weigh the credibility of expert witnesses alongside his judgment.

Questions of credibility came up Tuesday, when the Missouri Attorney General’s Office called as a witness John Michael Bailey, a psychology professor at Northwestern who testified about his now-retracted study entitled “Rapid Onset Gender Dysphoria,” which concludes that adolescents identify as transgender as a result of social contagion.

But it was his social media post about the accusers of Jerry Sandusky that appeared to concern Carter.

Sandusky, a former college football coach, was convicted of molesting young boys over a period of at least 15 years. Bailey repeatedly posted on social media that he believes Sandusky is innocent.

“You believe the people testifying against Jerry Sandusky are lying?” Carter asked.

“I can see that if you are not familiar with the evidence that I am familiar with, you would be shocked,” Bailey told him.

“Mmhmm,” Carter replied.

Bailey said he had listened to a podcast and lauded the work of conservative commentator John Ziegler.

“Do you know (Ziegler)? Have you talked to anybody that was an eyewitness in that case?” Carter asked.

“I have read testimony, but I have not talked to anyone,” Bailey said.

Although the underlying case was not about Sandusky, the exchange may have chiseled away at Bailey’s credibility and showed a greater pattern of basing conclusions on secondary sources.

Bailey’s research on transgender youth has been retracted, which he chalked up to pressure from activists.

The academic journal that retracted his article cited an issue with informed consent protocol, meaning participants didn’t know their responses would be in an article. On cross-examination, the circumstances of his research became clearer.

To investigate his hypothesis of whether “rapid onset gender dysphoria” caused a rise in referrals to gender clinics, Bailey surveyed parents and guardians who interacted with the website ParentsofROGDKids.com, a website for parents who believe their child has rapid onset gender dysphoria.

He said the study’s co-author Suzanna Diaz isn’t a researcher, so she didn’t create the survey with typical informed-consent procedures. He didn’t explain that Diaz is a pseudonym.

He knew Diaz was associated with ParentsofROGDKids.com but didn’t know her real name and if she ran the website.

Diaz had created the questionnaire to “weed out troublemakers.”

When Bailey looked into detransitioners and desisters, which are people who have stopped or reversed gender-affirming care, he looked to the website Reddit and looked at groups titled “detrans” and “desist.”

Plaintiffs’ attorney Nora Huppert asked if he verified that participants had previously been diagnosed with gender dysphoria. Bailey admitted that he had not.

The other defense expert on the stand Tuesday was Dr. Daniel Weiss, an endocrinologist from Utah.

For 10 years in Ohio, Weiss accepted transgender adults as patients that needed cross-sex hormones, but later decided the intervention was harmful to prescribe.

“I’m opposed to it medically,” Weiss said of adults using cross-sex hormones to transition. “I think there’s no scientific evidence to support it. But if someone wants to do it, and they’re adequately informed, they can do it.”

His testimony included a look at adverse event reporting of puberty blockers, which he does not prescribe, and the discussion of risks to gender-affirming care.

When asked to compare the risks of puberty blockers to aspirin, he couldn’t make a direct comparison.

“It’s hard to compare,” he said. “With any intervention, you want to balance risk and benefit and look at all the treatment options.”

Gillian Wilcox, an attorney with the ACLU of Missouri, asked if he has published a peer-reviewed article on gender dysphoria. He hadn’t.

“My article, if I were to write one, would be rejected by most medical journals because there is no good treatment,” Weiss said. “I call it child-harming treatment. There is no good intervention.”

He has testified in favor of state bans on gender-affirming care for minors. He told Wilcox that the Center for Christian Virtue, an advocacy group with anti-LGBTQ views, asked him to testify and he was paid to prepare his testimony.

He does not have clinical experience with minors.

In the state’s pretrial brief, Solicitor General Joshua Divine wrote that defendants will only need to prove “medical and scientific uncertainty” to show that state lawmakers are allowed to enact restrictions on gender-affirming care.

Although the state has entered the trial confident in the task ahead, credibility may limit what the judge will consider from its experts.

Other witnesses Tuesday included parents, one of which lives in Chicago, who disagreed with their children about their transition.

Advocates are raising alarm that certain people who still need services will lose them, causing their health to decline or forcing them into institutional settings like nursing homes (Scott Olson/Getty Images)..

Nearly 8,000 seniors and Missourians with disabilities could lose at-home care over the next year after a new eligibility algorithm went into effect this week, a spokesperson for the state health department told The Independent.

Starting Oct. 1, Missouri’s Department of Health and Senior Services implemented a change in the scoring algorithm they use to determine eligibility during annual reviews and enrollment for those receiving help with everyday tasks like going to the bathroom, getting dressed and taking their prescriptions. The assistance is part of a Medicaid-funded program called home and community based services designed to provide an alternative to those who would otherwise need to receive institutional care. 

That change, according to the department, is designed to help ensure those who truly need the services receive them, and those who don’t — for instance, because their conditions have improved or they’re not severe enough to qualify — are removed.

“We want to ensure those with higher acuity needs are receiving the care they need,” said DHSS spokesperson Lisa Cox. “That is what this transformation is about—to ensure we are providing the right services, in the right setting, at the right time to those who would go into a facility placement if not for [home and community based services].”    

But advocates are raising alarm that certain people who still need services will lose them, causing their health to decline or forcing them into institutional settings like nursing homes. 

Jennifer Gundy, who runs a center for independent living in southwest Missouri, which provides in-home care support for 370 people, estimates 18% of her clients will fall off the rolls.

And most of them will still be in need of services, she said, including cases of those with severe diabetes, mobility issues, complicated medication regimes and other issues that are eased by current assistance but will worsen without it.

“So that’s our concern,” she said. “And we’ve been voicing that concern with the state for probably the last two years,” she said.

Joel Ferber, director of advocacy at Legal Services of Eastern Missouri, said there are “truly needy folks who are going to lose services.” 

Legal Services of Eastern Missouri has been working with national advocacy groups to analyze the new algorithm and its effects, and provide guidance. One client they identified, a 70-year-old woman who receives 40 hours of weekly paid help, won’t be eligible after her review, according to LSEM. She weighs under 100 pounds and has had a stroke.

Without a caretaker, she won’t be able to make herself meals or bathe, and has no family in the area. She may have to be hospitalized or go to a nursing home.

State Rep. Deb Lavender, a Democrat of Manchester, said thousands will lose services, “without any support from the state” to fill in the gap.

“They’re going to be people who have received services for years,” she said, “and we have provided that for them — to then drop them because they don’t meet the new algorithm doesn’t seem right.”

Cox said 7,818 people are at risk of losing services, but she didn’t provide an estimate of any possible net change, saying the program will “continue to add more participants every month due to the increase in needs of our population.” New people will also qualify based on the new algorithm, adding to the population, she said.

From 2021 to last month, the department used both the new and old algorithm, so that anyone who qualified on either basis could qualify for the program. Cox said thousands of people have gained access to services under the new algorithm who wouldn’t have qualified on the old calculation: She said 7,708 people have gained eligibility under the new algorithm since it was introduced in Nov. 2021.

There were around 68,000 people monthly on the program last fiscal year, Cox said.

The new algorithm has been years in the making. 

The legislature in 2017 grew concerned with the home and community based services program “just blossoming” in participation and cost, said Jessica Schaefer, program director for home and community based services in a recent training. 

To cut the budget, the legislature in 2017 raised the threshold for eligibility. It also capped costs for services at a lower level. 

The program is jointly funded by the state and federal government, and states vary widely in how they run the programs.

The department found those changes weren’t entirely effective, Schafer said — that some people who needed services most didn’t qualify anymore — so they launched a “transformation” of the eligibility criteria. It was designed to be more accurate at directing limited services to the correct people.

The “transformation is about ensuring those most in need of care receive the services needed to remain independent in their community,” Cox said.

There have been several delays in implementing the new algorithm — most recently because of federal rules tied to accepting American Rescue Plan Act funds. 

The state has generally characterized those who will lose coverage as people who don’t have needs significant enough to qualify in the first place.

In a slideshow for providers during a recent training, the state recommended when delivering the news of ineligibility to individuals, that they “exude confidence” and “put a positive spin on ineligibility,” along with connecting them to other resources and expressing sympathy.

Because the department has been providing two scores, advocates can see which clients will not qualify under the new algorithm and have been able to track it.

Advocates say they’ve repeatedly brought up concerns with the state based on clients they see are desperately in need of services who will no longer qualify.

“The only thing that we can do is just go ahead and allow them to do this, and then if there’s enough people that fall off the services and end up going to the nursing home, going in the hospital, having lots of problems because they’re not getting the services, then we can look at doing a class action lawsuit,” said Gundy, the southwest Missouri advocate.

“Which is really sad, because those people have to get hurt or have really bad health problems for something to get done.”

States across the country have made similar cuts to the program, based on automated decisions, including in Arkansas, where the algorithm was successfully challenged in court.

Legal Services of Eastern Missouri and a group of national advocates published a toolkit for providers and participants to understand the changes and track those who lose services.

Emily Paul, project director at Upturn, a national organization that advocates for equity and justice in technology, has been involved in that analysis.

“What we understand in general is that automation is a tool that states are using to deal with inadequate funding for these programs, and to create a rationale for who doesn’t get services,” Paul said.

“Underfunding really drives the need to have this whole rationale for trying to distribute the resources and trying to make claims to fairness and objectivity within a system that is not really set up to actually meet people’s needs,” she said. “And so that’s the fundamental issue. States can still try to make better or worse choices about how they allocate the resources.”

This story was updated at 9:10 A.M. with additional comment from the Department of Health and Senior Services.

A new report details more than 200 cases of women charged criminally for their behavior while pregnant in the year after the 2022 U.S. Supreme Court decision that dismantled the constitutional right to abortion (John Moore/Getty Images).

In the year after the U.S. Supreme Court dismantled the constitutional right to abortion in June 2022, more than 200 pregnant women faced criminal charges for conduct associated with their pregnancy, pregnancy loss or birth, according to a new report.

The report was produced by Pregnancy Justice, a nonprofit that advocates for the rights of pregnant people, including the right to abortion. Researchers in multiple states documented 210 cases of women being charged for pregnancy-related conduct in 12 states from June 24, 2022, to June 23, 2023, the first year after the U.S. Supreme Court eliminated the constitutional right to an abortion, throwing the issue to the states.

The majority of charges alleged substance use during pregnancy; in two-thirds of cases, it was the only allegation made against the defendant. Six states — Alabama, Mississippi, Ohio, Oklahoma, South Carolina and Texas — accounted for the majority of cases documented by researchers.

The new report utilizes improved data collection, making comparisons with previous versions difficult. But “what we found was even more of an acceleration in pregnancy criminalization as compared to before” the Supreme Court’s ruling, said Lourdes Rivera, president of Pregnancy Justice. Rivera said she thinks that in states with abortion bans or new restrictions, there is more scrutiny of pregnancy loss.

However, almost none of the prosecutions documented by researchers were brought under state abortion laws. Instead, researchers found that law enforcement most often charged pregnant women with crimes such as child neglect or endangerment, interpreting the definition of “child” to include a fetus. In doing so, authorities relied on a legal concept called fetal personhood — the idea that a fetus, embryo or fertilized egg has the same legal rights as a person who has been born.

“If we focus only on abortion laws, we miss a crucial part of the picture in the fact that pregnant individuals are being criminalized for allegedly endangering their own pregnancies, for pregnancy loss and, in some cases, for conduct related to abortion,” Rivera said. “What’s driving pregnancy criminalization is the expansion of fetal personhood.”

Charges of child abuse or endangerment carry stiffer penalties — higher fines and lengthier prison sentences — than the low-level drug charges the women likely would have faced had they not been pregnant.

“Pregnancy-related prosecutions don’t generally charge crimes that, on the face of the criminal statute, have anything whatsoever to do with pregnancy,” said Wendy Bach, a professor at the University of Tennessee College of Law and the report’s principal investigator. “Instead, using the idea of fetal personhood, or more specifically the idea that the fetus can be the victim of a crime perpetrated by the pregnant person, they use that theory to charge general crimes.”

The push for charges

Conservative lawmakers in Alaska, Illinois, Missouri, South Carolina and West Virginia introduced fetal personhood bills in the most recent legislative session, though none made it out of committee. In Nebraska, dueling amendments will appear on the ballot. One would codify the right to abortion until “fetal viability,” about 24 weeks. The other would amend the state constitution to restrict abortion to 12 weeks and protect “unborn children” in the second and third trimesters of pregnancy.

Proponents of charging pregnant women for conduct that could harm a fetus argue that the threat of prosecution incentivizes the women to get care or treatment for substance use disorders.

Jody Willoughby, the Republican district attorney in Etowah County, Alabama, which has long had some of the highest numbers of pregnancy-related arrests in the country, has said publicly that his office prosecutes cases because doing nothing would make his office “an enabler of a deadly addiction, complicit in the abuse of a child, and ultimately lead to the death of a mother,” local news outlet AL.com reported in 2022. Willoughby did not respond to Stateline’s requests for comment.

But critics say the arrests and prosecutions deter people from seeking care for fear they’ll be arrested or lose custody of their children. The majority of defendants identified in the report had low incomes; most were white.

All six of the states that accounted for most of the cases cited in the study have fetal personhood language baked into their laws. Seventeen states have laws with broad fetal personhood language that could apply to all criminal laws, according to an analysis by Pregnancy Justice.

When it comes to prosecuting pregnant women, Alabama leads the nation: The state accounts for nearly half of the prosecutions documented in the report. Alabama has a constitutional amendment, approved by voters in 2018, that explicitly confers personhood on fetuses and affirms the state’s responsibility to protect “the rights of unborn children.” All the cases documented in Alabama were brought under its chemical endangerment law, which the Alabama Supreme Court ruled in 2013 can include fetuses.

Most of Alabama’s cases come from just a few counties. They were long considered outliers, places where a handful of overzealous officials liberally applied the state’s chemical endangerment law to hundreds of pregnant women.

But Brittany VandeBerg, who led the research in Alabama, said that chemical endangerment charges have popped up in a dozen more Alabama counties since the Dobbs ruling.

“In each county the district attorney really steers the ship as far as what type of priorities they have in their office for prosecutions,” said VandeBerg, who is associate chair of the department of criminology and criminal justice at the University of Alabama. “I don’t know if the elected district attorneys feel this is what the community wants, or if it’s their own personal feelings. But the system is in place to move those cases forward.”

VandeBerg said Alabama provides relatively meager resources for people struggling with addiction. That leaves law enforcement feeling like they have no options other than to arrest and jail women with substance use disorders, she said.

“There just aren’t enough inpatient treatment facilities to help these women,” VandeBerg told Stateline.

One of the things that stuck out to VandeBerg in reviewing cases was the large share of incidents in which a pregnant woman was charged with chemical endangerment even though her baby exhibited no signs of harm after it was born.

“I found that incredibly shocking,” said VandeBerg, who noted that Alabama’s chemical endangerment law can result in a 10-year prison sentence — much longer than some domestic violence crimes carry. “Here, they’re charging the mother before we know harm has been done.”

Defendant exonerated

In July, an Oklahoma court exonerated a woman who’d been charged with felony child neglect in 2020 after her son tested positive for marijuana at birth. Prosecutors pursued the case even though her baby was born healthy, and she’d had a doctor-approved state license to legally use medical marijuana to treat severe morning sickness during the pregnancy.

Brian Hermanson, an Oklahoma Republican district attorney who’s prosecuted dozens of women in his district in similar circumstances, used fetal personhood language in his legal argument.

“Marijuana is an illegal drug under Oklahoma law unless the person consuming the marijuana holds a medical marijuana license. Unborn babies cannot hold such a license,” Hermanson wrote in a court filing.

“[The defendant] admitted to smoking marijuana throughout her pregnancy, knowing that her unborn baby was being exposed to the possible harmful effects of the marijuana smoke.”

The Pregnancy Justice report also documented five cases in which allegations specifically mentioned abortion. One was brought under a state abortion statute that has since been repealed. The other four cases were charged as homicide, child neglect or abuse of a corpse. In the two cases in which homicide was charged, the defendants allegedly visited an abortion clinic or took pills and the abortion was successful, Rivera said.

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

A former case worker of the Washington University Transgender Center at St. Louis Children's Hospital testified Monday in the trial challenging Missouri's restrictions on gender-affirming care (Rebecca Rivas/Missouri Independent).

The former caseworker whose account of her time working at a pediatric gender clinic in St. Louis jumpstarted the legislative push to outlaw gender-affirming care for minors testified in defense of Missouri’s restriction on Monday.

Jamie Reed, who for four and a half years worked as a case manager at the Washington University Transgender Center, was the first witness called by the state in the two-week trial over the constitutionality of the law. Reed’s public statements and sworn affidavit about her experience at the clinic were the genesis for Missouri lawmakers prioritizing the ban and spurred broad investigations by the Missouri Attorney General’s Office into practitioners statewide.

Reed testified as a fact witness, meaning she couldn’t speak as an expert but could provide insight into her experiences working at the Transgender Center. Many of Monday’s questions gravitated toward the records she kept — and later shared — that contained information on the center’s patients.

Under the 2023 law, health care providers can’t prescribe new gender-affirming care medications to minors or refer them for surgery, and the state’s Medicaid program is barred from paying for gender-affirming medical care for any age. Transgender Missourians, their families and health care providers filed a lawsuit in July 2023, calling the law unconstitutional because it discriminated against transgender people.

Therapists, social workers face scrutiny in Missouri AG investigation of transgender care

Last week, plaintiffs called witnesses that testified that their medical record numbers and treatment information were listed in a document that Reed shared with Attorney General Andrew Bailey and at least one reporter.

When asked Thursday about his daughter’s information being shared, J.K. (who testified using his initials as a pseudonym) said he never consented to the information being spread.

“It’s confusing and mystifying,” he said. “I don’t know why this person would share our information. I have no idea what this person is up to.”

He didn’t interact with Reed, he said, apart from getting an email after an appointment with follow-up information from her. But somehow, his daughter’s information was in Reed’s table.

Elliott, a college student who went to the Transgender Center as a teenager and testified using only their first name, said Friday that Reed was never in appointments with them. Elliott is “terrified” that the attorney general has information related to their medical care.

“I don’t know what they’ll do with that information,” Elliott said. “I don’t think it’s any of (the state’s) business that I’m trans.”

Elliott also thought Reed’s affidavit, which was released to the public, described them in a paragraph that was so specific friends and family could identify them.

“I was extremely upset (when I read the affidavit),” Elliott said. “I didn’t think it was an accurate representation of the care I received at Wash U. There was a line I thought could represent me, and if so, I am angry that I was used without my permission.”

Reed testified on Monday that this part of her affidavit was describing multiple patients. Other paragraphs talking about “a patient” were also a compilation of more than one person, she said.

The affidavit was based on medical records, patient visits and “firsthand knowledge” she testified. 

Reed didn’t dispute that Elliott’s information was shared in a 23-page document that listed patients’ medical record numbers instead of names. She didn’t consider this private health information protected by federal law because someone would need a key with names alongside medical record numbers to identify patients.

She sent this data to Bailey after a subpoena, she testified, but she also sent it to a New York Times reporter.

Plaintiffs’ attorney Gillian Wilcox asked about the 300 pages sent to the reporter. Reed said she sent “redacted documents that contained no (private health information).”

Reed, for part of her time at the Transgender Center, tracked patients she was concerned about on a “red-flag list.” She called it that because red flags at the beach mean to “proceed with caution,” she testified.

There were 27 patients on the list, identified by name instead of medical record number. Reed says she monitored them with a nurse at the center who shared concerns with Reed that too many children were receiving cross-sex hormones and puberty blockers.

Reed sent this list to Bailey in early February 2023 at the time of her affidavit, she said.

Other records she sent to Bailey include emails compiled from her Washington University email account, a list of therapists the center often referred patients to and copies of referral letters from therapists.

Reed told The Independent previously that she redacted names in the referral letters. This was not asked in court Monday.

Wilcox asked about a letter Reed sent Bailey in April 2024, long after she ended her employment with the Transgender Center.

The letter shared information from the center’s schedule that Reed believed showed the center was accepting new patients, despite public statements that it would not.

Reed currently works as executive director of the LGBT Courage Coalition, a nonprofit that advocates against gender-affirming care for transgender youth.

She recently traveled to the American Academy of Pediatrics convention in Florida to help volunteers “educate” pediatricians on gender-affirming care. A press release on the group’s participation described it as a “peaceful protest,” but Reed did not characterize the demonstration as a protest.

She wouldn’t answer whether she supported gender-affirming care for adults or not, though she had indicated support in prior testimony. She cited “changes in (her) personal life.”

At the beginning of questioning, she testified that her spouse was “detransitioning,” or stopping testosterone treatments. Sunday evening, her spouse’s perspective was published in The Free Press, the same website that launched Reed as a whistleblower in February 2023.

Christian King, a doula with Uzazi Village in Kansas City, wraps Mikia Marshall, 33, with a kanga cloth to help take pressure off her stomach on Feb. 27, 2024 (Anna Spoerre/Missouri Independent).

In an effort to address Missouri’s deplorable maternal mortality rates, the state issued an emergency rule Monday allowing doulas to be reimbursed through Medicaid for the next six months. 

Doulas — who offer support for families during pregnancy, delivery and postpartum, but do not deliver babies — have been lifted up as one solution to improving maternal and infant health outcomes, especially among low-income families.

Missouri ranked among the bottom half of states for maternal deaths between 2018 and 2022, according to the Centers for Disease Control and Prevention.

“There are evident disparities in the risk of maternal mortality by ethnicity and race, maternal age, access to care, and socio-economic status. Utilizing doula services may reduce maternal mortality, health disparities and improve maternity care for women in Missouri,” the rule states. 

The state Department of Social Services will begin reimbursing doula services to low-income women through MO HealthNet, the state’s Medicaid program, on Tuesday. The program will last through March 28 in the hopes of improving birth outcomes. 

News of the rule change was first reported by the St. Louis Post-Dispatch.

The emergency rule is only six months, but a longer term plan is in the works. On Sept. 27, the Department of Social Services provided public notice of intent to submit a permanent plan.

The program reimburses six total prenatal and postpartum doula visits, attendance at a birth, lactation education services and help navigating community services. Doulas often visit new mothers at their homes during the postpartum period, watching for signs of depression, addiction and violence, all of which have been found to be leading causes of death for women in the year after giving birth.

“There is potential for an offsetting savings in year two and beyond based on the potential reduction in the Cesarean rate as well as other improved birth outcomes,” the rule said.

To be eligible, doulas must be credentialed and certified through a national or Missouri-based doula training organization. From there, they will be added to a list of eligible doulas overseen by the Missouri Community Doula Council.

“I’m pleased to see that ruling,” Hakima Payne, co-founder and CEO of Uzazi Village, said Monday. “It’s a step in the right direction for improving maternal and infant health in Missouri and I’m glad to see the state taking that step.” 

Payne, whose Kansas City nonprofit works to improve birth outcomes, including through doula training programs, said she hopes to see the reimbursement made permanent.

Missouri has long been among the states with the worst maternal health outcomes in the country. 

In Missouri between 2017 and 2021, women on Medicaid were seven times more likely to die within a year of pregnancy than women on private insurance, according to a report published Aug. 30 by the state’s Pregnancy-Associated Mortality Review. 

In those five years, 349 Missouri women died while pregnant or within a year of pregnancy. Black mothers in that time frame were 2.5 times more likely to die within a year of pregnancy than white mothers. 

Of the 70 or so pregnancy-associated deaths each year in Missouri, 77% were deemed preventable. Cardiovascular disease and mental health conditions were among the main causes of pregnancy-related deaths.

“DSS finds an immediate danger to the public health, safety or welfare of pregnant women in Missouri, which requires this emergency action,” Monday’s emergency rule stated. 

A 2023 March of Dimes report gave Missouri a D- for preterm births, and also pointed to doulas as a solution.

The report recommends that health care facilities work with social workers, community health workers and doulas during patients’ pregnancy and post-partum periods, in part to address social determinants of health. 

Missouri doulas give up wages to serve women on Medicaid. Legislators hope to fix that

Okunsola Amadou said formal conversations between doulas and the state around Medicaid reimbursements go back years.

Amadou is founder and CEO of Jamaa Birth Village in Ferguson, the oldest community-based doula organization in the St. Louis region.

In spring 2022, Amadou and Payne were among several people who co-authored a policy brief that highlighted the benefits of doulas on health outcomes and urging “innovation” to bring doulas to more women, particularly those with high-risk pregnancies.

“This policy brief was the trusted, evidence-based document that informed the entire state of Missouri on the importance of doulas,” Amadou said.

When the emergency rule was announced, Amadou said she finally breathed a sigh of relief.

She noted that while the emergency rule, which holds until a permanent plan is finalized, would not financially cover every woman who could benefit from a doula, organizations like Jamaa Birth Village and Uzazi Village will continue to offer scholarships programs for doula services as well.

“We will always back up our community where the state is still trying its best to answer the call,” she said. “ … We have to start somewhere, and I just want to applaud the state for starting somewhere.”

Christian King, a doula in Kansas City who in March told The Independent she had reduced or given up wages to provide services to women on Medicaid who couldn’t afford the assistance, said Monday the state just created a huge opportunity. 

“I hope that with government funding, our hospitals and health training institutions begin to welcome doulas,” King said. “But also respect us and allow us to support birthing persons and their families without a power struggle.”

The order came months after identical bills that would’ve allowed doulas registered with the state to be reimbursed through insurance died before the end of session. The legislation was filed by state Reps. Wendy Hausman, a Republican from St. Peters, and Jamie Johnson, a Democrat from Kansas City. 

Improving the state’s birth outcomes has been heralded as a bi-partisan issue.

In 2023, the Missouri legislature extended postpartum Medicaid coverage from 60 days to one year. Several months after he signed the bill, Gov. Mike Parson called on the state to do more to improve birth outcomes, which he called “embarrassing and absolutely unacceptable.”

This story was updated at 11 a.m. to clarify the financial cost and timeline of the emergency rule, and to add comments from Okunsola Amadou, with Jamaa Birth Village in Ferguson.

In the last decade, 2,000 Walgreens pharmacies have closed, including this one at Troost Avenue and Emanuel Cleaver II Boulevard. (Vaughn Wheat/The Beacon)

Less than two years ago, neighbors near Brush Creek Boulevard and Troost Avenue had choices when they needed to pick up a prescription — or a carton of milk.

A CVS pharmacy stood on the northeast corner of their intersection. Its retail rival, Walgreens, was just a block south at Troost and Emanuel Cleaver II Boulevard.

But today, a beauty supply store sits in the old CVS space. The pharmacy closed in April 2023. And the Walgreens, which had moved out five months before, remains empty. Weeds sprout through cracks in the parking lot and graffiti marks the drive-thru window.

Now people in this part of Kansas City, home to some of its poorest neighborhoods, may have to catch a bus just to fill a prescription. Even if the buses are running on time and it only takes 10 minutes at the drugstore, the round trip to the nearest CVS or Walgreens would take nearly two hours.

“When you don’t have something close to where you live,” said Alana Henry, the former executive director of the Ivanhoe Neighborhood Council, “it makes life more complicated.”

Retail pharmacies are shutting down in places like Kansas City and Wichita across the country, posing a growing worry for health experts. It’s most acute where the incomes are lower, in urban cores and small towns where pharmacies act as convenience stores of the health care system.

“When those community pharmacies close,” said Lucas Berenbrok, an associate professor at the University of Pittsburgh School of Pharmacy who has been mapping closures, “communities lose critical access.”

Why losing pharmacies matters

Kansas City has lost close to 100 pharmacies in the last 10 years. CVS closed at least 11 stores, including one on Independence Avenue this summer. Walgreens shut down five, and another on East 63rd Street is expected to close at the end of the September.

Nationally, Berenbrok’s mapping shows about 7,000 pharmacies shuttered since 2019. His analysis doesn’t yet include what’s believed to be a far smaller number of stores that have opened.

“It matters that someone lost access to care,” Berenbrok said.

The closings come at a time when, an Associated Press analysis found in June, people in majority Black or Latino neighborhoods and rural residents already have the fewest pharmacies per capita. Pharmacies also tend to represent a critical source of health care — sometimes the only one.

Some chain stores even operate urgent-care clinics, where patients can get tested for strep throat or prescribed an antibiotic.

When Walgreens and CVS pulled out of their Troost locations, residents said goodbye to two important anchors in their community, said Bill Drummond, a glass artist who lives in the nearby Manheim neighborhood.

“Community health is what it was,” he said.

Yes, the prescriptions. But also a place to check your blood pressure, get a flu shot or other vaccination, get COVID tests. Most importantly, somebody there could answer medical questions.

Russell B. Melchert, dean of the University of Missouri-Kansas City School of Pharmacy, said pharmacists have always filled that role. When COVID hit, that became even more clear.

Pharmacies picked up some of the work that overcrowded hospitals or temporarily shuttered doctor’s offices would normally handle. And as the shortage of primary care providers increases wait times for appointments, the need for pharmacists keeps expanding.

“We have a gap in primary care services,” Melchert said. “And that’s for people who have health insurance. What about the many hundreds of thousands who don’t? They have nothing.”

Why are pharmacies closing?

To understand why pharmacies are closing, it’s helpful to understand the terrain that has shaped them: Steep climbs in the number of prescription drugs available and deep canyons in the profits those drugs bring in.

Until the 1960s, pharmacies sold medicine directly to consumers. A patient left the doctor’s office with a prescription, took it to the neighborhood drugstore and paid whatever the pharmacy charged.

Then came prescription insurance coverage, which started small 60 years ago and quickly expanded. It reached near ubiquity in 2006 when Medicare added drug coverage. The industry helped open a flood of new drugs — and gradually determined what drugs you could get and how much a pharmacy would get from sales.

In 1950, every American took an estimated 2.4 prescription drugs each year. By 2015, that shot up to 17.3, according to a textbook written by Lawton Robert Burns, a management professor at the University of Pennsylvania.

Today, just under 10% of U.S. health care spending goes to drugs. That’s out of the $4.5 trillion on all health care, or $13,493 per person. In 1970, per capita health care spending was only $353, or around $2,000 in 2022 dollars.

The money to be made on prescription drugs drew chain pharmacies like CVS and Walgreens to buy out family-owned drugstores and build new stores — often within blocks of one another.

But the chains’ building boom in the 1990s and early 2000s has been followed by retreat in the last decade. (It doesn’t help that the chains are also absorbing multi-billion dollar settlements of lawsuits over their roles in the opioid crisis. In 2022, CVS agreed to pay $5 billion, while Walgreens agreed to pay $5.7 billion.)

For reasons that involve the complicated way insurance companies reimburse pharmacies for drugs, profits from prescriptions began to fall. In many cases, they plummeted so much that pharmacists couldn’t cover their costs.

On top of that, buying habits changed. People started getting medicine through the mail and buying shampoo, toothpaste and other front-of-the-store products online.

That’s why the drugstore on your block may have closed or could be next.

The story is especially dire for small independent stores. The National Community Pharmacists  Association estimates that one independent pharmacy closed every day of 2023, and the organization expects a similar trend this year.

Even chain stores feel the pinch.

CVS has closed 850 stores since 2022. It expects to close 50 more this year. Walgreens has closed 2,000 stores over the last decade. Now it’s deciding whether to shutter an additional 2,150 that the company calls “underperforming.” That’s one in four of its remaining retail locations.

Executives with Walgreens Boots Alliance Inc., Walgreens’ owner, told analysts in a June stock earnings call that they would only stick with stores that are making money. The rest have to go.

Losing access to care

Tessa Schnelle, a pharmacist who has studied pharmacy deserts in rural Kansas, worries people underestimate the punch coming to the health care system.

Her research found that 210 Kansas towns are in a rural pharmacy desert, which she defines as having residents who live 10 miles or more from a pharmacy. On average, people within those deserts live about 13 miles from a pharmacy. But she expects that to continue to get worse as more pharmacies are forced to close.

Schnelle, past president of the Kansas Pharmacists Association, often hears people dismiss concerns about pharmacies being far away. After all, people can get drugs through the mail. Or, as is happening in limited capacity, from a pre-stocked vending machine.

But those solutions easily fall apart without much scrutiny, she said.

“What if I have an ear infection?” she said. “And they’re going to prescribe an antimicrobial? There is no place for me to get that, and it’s going to take multiple days for me to get that from the mail order. … And there’s no one to educate me if I’m getting it from a (vending machine).”

The same goes for home delivery pharmacies, which are becoming more common, Schnelle said. Even if those services can get the medication to patients, having the drugs without the pharmacist has drawbacks.

Pharmacists play a much bigger role than just counting pills and putting them in bottles, she said. They’re looking for dangerous drug interactions and allergies. Or they’re listening to a patient’s symptoms and realizing that they might be having a reaction to a medicine.

“Pharmacists are the brakes,” she said. “They’re there for a reason.”

Missouri has two counties — Knox and Schuyler, in the state’s northeast — without any pharmacy. And 16 counties in the state have only one.

James Johnston added another county to the list with zero when he closed down Knox County Pharmacy in 2022. He’d opened it a decade earlier when he was already running Johnston Drug in Clarence, Missouri.

The 38 miles between the two stores simply became too much.

“I just about wore all my people out,” he said. “You don’t get away very often and very seldom do you leave on time.”

He said the Knox County store “had a nice business.” But selling a pharmacy in the current market, when drug reimbursement rates are so low, is difficult. And selling a pharmacy in a remote town is even harder.

“No one would bite,” he said. “You are never off duty when you’re the one-man band.”

Johnston sold his patient files to a grocery store pharmacy in Kirksville, 31 miles away. But he knows that wasn’t ideal for his customers.

A hard profession to sell

Meanwhile, across the board, pharmacies are having a harder time finding pharmacists — particularly in rural areas.

“It’s a crisis,” Melchert said. “But let me tell you how bad it’s going to get.”

In 2023, the country had 14,000 pharmacy graduates.

“Within four years,” he said, “that number is going to be about 8,000.”

That is well below the 13,500 new pharmacists the U.S. Bureau of Labor Statistics estimates will be needed annually to make up for those retiring or leaving the profession.

The UMKC Pharmacy School, which is at less than 70% capacity, is typical. Pharmacy schools across the country are seeing declining enrollment, even though pharmacists can make six figures straight out of school. Scholarships and student loan forgiveness can also get thrown in. Some chains pay signing bonuses.

Enrollment was falling off before the pandemic. COVID just made things worse. Melchert suspects some would-be students may not see the profession in a very positive light after a trip to a crowded chain store, where frazzled pharmacists may juggle telephone calls, administer vaccines and scroll through computer files.

“People just don’t know what it is we do,” Melchert said.

He and other pharmacy school deans argue that people don’t know just how big a role pharmacists play in modern health care. They are doing all they can to draw more people into the profession. That includes consulting with large corporate owners like CVS and Walgreens about how to improve working conditions, and training high school students to take jobs as pharmacy technicians.

Nate Rockers, who owns Rockers Pharmacy in Paola, Kansas, said he wouldn’t dream of asking either of his two sons to join him and take over the family store.

“I can’t envision being in business for 20 more years and retiring as a pharmacy owner,” he said. “I don’t know if pharmacy will be around as we know it in five years if we don’t do something. Once the ship sinks, it doesn’t come back up.”

This article first appeared on Beacon: Missouri and is republished here under a Creative Commons license.

Judge Craig Carter, a Wright County judge serving in Cole County for Missouri's gender-affirming care trial, listens to a nurse practitioner testify Thursday afternoon (Annelise Hanshaw/Missouri Independent).

After three days of battling over scientific papers and expert testimony, the trial of a lawsuit challenging Missouri’s restrictions on gender-affirming treatments on Thursday turned to the impact the law has on patients and providers.

Nicole Carr, a nurse practitioner at Southampton Community Healthcare in St. Louis, said anxiety, fear and depression first increased in transgender patients when Attorney General Andrew Bailey published an emergency rule that established barriers to care in April 2023.

“No one thinks about how these laws affect the actual people they are supposed to protect and they are supposed to serve,” she said.

Patients were crying in the clinic in fear, she testified.

“I’m trying to give them hope that they don’t have to fear being in Missouri, that they don’t have to fear coming to me as a provider, that they can move past this,” Carr said. “It’s sad because I’m referring a lot of people to therapy that, before these rules, were fine.”

She worries about youth in foster care, which she worked with frequently in a previous position. Transgender teenagers in foster care often must wait until they turn 18 to go to the doctor alone for assessment to obtain hormone-replacement therapy.

But if they are on Medicaid, as most are soon after foster care, Missouri won’t pay for the treatment.

“(The law) has impacted the quality of care I can give my patients when I know the solution to their problem is out there and I can’t do anything about it,” she said.

Carr and Southampton healthcare are among 11 plaintiffs hoping to block enforcement of a 2023 law banning gender-affirming medical treatments for minors. Other plaintiffs include parents of transgender children, transgender adolescents, other medical care providers and organizations supporting gender-affirming care.

Their attorneys began putting witnesses on the stand Monday in the Cole County Circuit Court trial scheduled to continue through next week. The lawsuit asks Judge Craig Carter, assigned to the case from Wright County, to declare the law unconstitutional, alleging violations of equal protection, due process and other rights guaranteed by the Missouri Constitution.

Although the law does not ban counseling or the continuation of treatments begun before it passed, several providers ceased all gender-affirming treatments for minors soon after it took effect on Aug. 28, 2023. First University of Missouri Health, then Washington University  in St. Louis, ended their programs, citing the threat of future litigation allowed in the law.

Neither provider is a party to the lawsuit.

Over the first three days of the trial, assistant attorney generals defending the law have repeatedly sought to discredit plaintiffs’ expert witnesses. The painstaking cross examinations have slowed the pace of the trial to two experts per day and led to a late recess on Wednesday.

Carter, however, has declined to limit the cross-examination, despite arguments from plaintiffs’ attorneys that it means the trial will exceed the time allotted to complete it.

During cross-examination, members of the defense team have read scientific articles, news articles and editorials on gender-affirming care. Almost invariably, that leads to objections that the exhibits are new.

Carter has allowed reading as a way to challenge the credibility of witnesses by  showing deficiencies in their testimony, such as bias or poor memory.

“They seem to be reading a lot of newspaper articles and a lot of opinion pieces,” Omar Gonzalez-Pagan, an attorney for plaintiffs, told reporters. “If they wanted to introduce the opinion of some random person in the United Kingdom, they could have called them.”

During one question to Dr. Armand Matheny Antommaria from Solicitor General Joshua Divine, plaintiffs’ attorney Nora Huppert objected, arguing that it was as if Divine was testifying himself.

It came as Antommaria, a pediatric hospitalist and bioethicist at Cincinnati Children’s Hospital, answered questions slowly, often with a “yes sir” or “no sir,” correcting Divine’s questions.

“If you go to the key findings, the statement you’ve pulled out is not part of the key findings,” he said, after a question in which Divine asked about a singular sentence of a scientific article. The context is important, Antommaria told him, saying the overall report was the opposite of Divine’s characterization.

Divine also asked  if Antommaria’s religious beliefs or divinity degree should disqualify him as an expert.

“Given the nature of that particular degree, that does not disqualify myself,” he said.

Dr. Johanna Olson-Kennedy, an adolescent medicine physician at Children’s Hospital Los Angeles and medical director of the hospital’s center for transgender youth health and development, testified about her research linking distress about breast development to depression and anxiety. She also discussed benefits of gender-affirming care she has seen in her clinical experience.

Hal Frampton, senior counsel with the Alliance Defending Freedom, brought one of the 11 three-ring binders prepared for the Olson-Kennedy testimony to the podium. He flipped through the approximately three-inch binder, presenting studies and articles to question Olson-Kennedy’s research and concluding with videos from talks she gave years ago.

In one talk, she said people “get worked up” about certain surgical procedures that are part of gender affirming care.

Frampton asked if she doesn’t like people that get worked up. Olson-Kennedy said she was emphasizing the difference between gender-affirming surgeries.

“The seriousness of getting a sterilizing surgery is more severe than someone who needs a chest surgery,” she said.

He also asked about an interview she gave in which she spoke about being involved in social justice efforts.

“People being able to get access to medically necessary care is an advocacy issue,” she responded.

The defense is scheduled to begin arguments Monday, with a scheduled final day of Oct. 4.

(Getty Images).

Missouri has begun distributing summer food benefits for children and aims to finish by the end of the year, a spokesperson for the Department of Social Services told The Independent this week.

The aid was intended to be distributed during summer break, to help vulnerable kids avoid a drop-off in nutrition while they were out of school.

Missouri didn’t begin issuing the benefits until Sept. 19.

That’s faster than the state issued summer 2022 emergency benefits that were tied to the COVID-19 pandemic — those were not distributed until the following summer. And in 2023, Missouri did not accept federal pandemic summer food aid for children.

This year’s benefits are part of a federal program in its first year called Summer Electronic Benefits Transfer, or SUN Bucks, which is administered by states.

Each eligible child receives a one-time benefit of $120, loaded onto a card that can be used like a debit card to buy groceries.

Thirteen Republican-led states, but not Missouri, opted out of participating in the program.

Benefits for the program have so far been issued to 9,500 Missouri kids, out of the 490,000 kids estimated to receive benefits that amount to $58.8 million.

“[The Family Support Division] remains committed to disbursing benefits as swiftly and accurately as possible,” DSS spokesperson Chelsea Blair said, “with the goal of completing all disbursements by the end of the year.”

State officials said they dealt with technical issues that delayed federal approval and hindered earlier launch of the program. 

One issue is that “much of the data collection process for children enrolled in the National School Lunch Program is still manual at this time,” another DSS spokesperson, Baylee Watts, said — the department needs schools to submit data before they can determine eligibility for many of the kids.

The children who will be automatically eligible for the program are:

• Students who are eligible for free or reduced-price lunch during the school year;
• Households already enrolled in Supplemental Nutrition Assistance Program (SNAP) or temporary assistance; and
• Students who are in foster care, are experiencing homelessness or are migrants.

Missouri has so far issued benefits to foster kids, Watts said, and is next turning to kids whose families are already on SNAP or temporary assistance.

It won’t be until after Oct. 10 that the benefits for kids on free or reduced-price lunch will begin to be issued, she said, because that’s the deadline for schools to submit eligibility data to the department.

Benefits will be issued on an existing card if the family is enrolled in SNAP benefits or temporary assistance, or on a new mailed card if they are not. Families who need a new EBT card can request one by phone or the ebtEDGE mobile app.

SUN Bucks benefits will expire 122 days after they are issued, regardless of usage, so families must act quickly once the benefits are distributed. They should also keep the cards for next summer’s program, the state’s website advises.

Those who aren’t automatically eligible were required to submit an application. The window for applications closed Aug. 31, and any received thereafter will be considered for next summer’s program, the department said. The agency received 17,000 applications.

Next summer, Watts said, the agency is expecting benefits to be distributed during the summer months, because the proper infrastructure will be in place.

Idaho Attorney General candidate Raul Labrador at the Idaho GOP election night watch party at the Grove in Boise, Idaho on November 8, 2022. (Otto Kitsinger for Idaho Capital Sun)

Idaho Attorney General Raúl Labrador – along with attorneys general and other officials from 20 U.S. states including Missouri Attorney General Andrew Bailey – has accused the American Academy of Pediatrics of possible “violations of state consumer protection statutes” over its standards and recommendations for gender dysphoria care for children.

In a letter sent by Labrador on Tuesday, the attorneys general requested information detailing the academy’s evidence for its current recommendations for puberty blockers for gender dysphoria-diagnosed youth.

“Most concerning, AAP claims that the use of puberty blockers on children is safe and reversible,” Labrador’s office said in a press release. “This assertion is not grounded in evidence and therefore may run afoul of consumer protection laws in most states.”

Children with gender dysphoria “need and deserve love, support, and medical care rooted in biological reality,” Labrador said in the release.

“It is shameful the most basic tenet of medicine – do no harm – has been abandoned by professional associations when politically pressured,” Labrador said.  “These organizations are sacrificing the health and well-being of children with medically unproven treatments that leave a wake of permanent damage.”

The American Academy of Pediatrics, an organization made up of 67,000 primary care pediatricians, voted in August to reaffirm its 2018 policy statement on gender-affirming care and authorized development of an expanded set of guidance for pediatricians.

The organization could not immediately be reached for comment. But at the organization’s August 2024 leadership conference in Itasca, Illinois, American Academy of Pediatrics CEO and Executive Vice President Mark Del Monte emphasized that the organization is confident that the principles presented in the original policy statement, “Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents,” remain in the best interest of children, according to an Aug. 4 press release from the academy.

The decision to authorize a systematic review reflects the academy’s board’s concerns about restrictions to access to health care with bans on gender-affirming care in more than 20 states, according to the Aug. 4 release.

In Idaho, the Legislature passed House Bill 71, a law banning Idaho youth from receiving gender-affirming care medications and surgeries. It was signed into law by Gov. Brad Little in April 2023.

The law makes it a felony punishable for up to 10 years for doctors to provide surgeries, puberty-blockers and hormones to transgender people under the age of 18. However, gender-affirming surgeries are not and were not performed among Idaho adults or youth before the bill was signed into law, the Idaho Capital Sun previously reported.

Missouri lawmakers in 2023 banned gender affirming medication and surgical treatments for minors. The bill did not include criminal penalties but it did make providers subject to license action and lawsuits.  A trial is underway in Jefferson City in a lawsuit filed by providers and patients challenging the law.

What is in the American Academy of Pediatrics guidelines for gender-affirming care?

As outlined in its policy statement, the academy encourages pediatricians to use a gender-affirmative care model when treating young patients. The model encourages pediatricians to recognize that:

• transgender identities and diverse gender expressions do not constitute a mental disorder;
• variations in gender identity and expression are normal aspects of human diversity, and binary definitions of gender do not always reflect emerging gender identities;
• gender identity evolves as an interplay of biology, development, socialization, and culture; and
• if a mental health issue exists, it most often stems from stigma and negative experiences rather than being intrinsic to the child.

“Many medical interventions can be offered to youth who identify as (transgender and gender diverse) and their families,” the academy notes in its policy statement. “The decision of whether and when to initiate gender-affirmative treatment is personal and involves careful consideration of risks, benefits, and other factors unique to each patient and family.”

However, Labrador said treatments that suppress hormones or use puberty blockers may have adverse health effects to the patient, including interfering with neurocognitive development, compromising bone density and interfering with normal puberty experiences. He said the treatments may cause “harm particularly egregious” to children who “grow out” of the condition by the time they are adults.

But the American Academy of Pediatrics in its policy statement says that research shows that children who assert their transgender identity before puberty and who “know their gender as clearly and as consistently” as their cisgender peers benefit from the same level of social acceptance as those peers.

“More robust and current research suggests that, rather than focusing on who a child will become, valuing them for who they are, even at a young age, fosters secure attachment and resilience, not only for the child but also for the whole family,” the academy wrote in its policy statement.

But Labrador and the other state officials say they want more information on how the academy has come to those conclusions, especially when it comes to puberty blockers.

“The letter requests detailed information from the AAP regarding its communications and practices related to youth gender dysphoria and substantiation of the academy’s claims regarding the safety and reversibility of puberty blockers,” the attorney general’s press release says.

Other states joining Idaho in sending the letter to the academy, along with Missouri, include officials from Alabama, Arizona, Arkansas, Florida, Georgia, Iowa, Kansas, Louisiana, Mississippi, Montana, Nebraska, North Dakota, Ohio, South Carolina, South Dakota, Texas, Utah, Virginia and West Virginia.

Rudi Keller of the Missouri Independent contributed to this report.

This story was originally published by the Idaho Capital Sun, a part of States Newsroom.

(Marc Serota/Getty Images).

Two of every five Missouri adults owe money to medical providers, according to a survey published Tuesday by the nonprofit Missouri Foundation for Health.

Those debts include unpaid fees for services ranging from lab tests and doctors’ visits to emergency treatment and dental care. Often, the bills are from one-time or short-term medical expenses, the report states.

One in ten Missouri residents have more than $5,000 in medical debt.

The result is that Missourians with medical debt commonly cut back on spending for basic needs, exhaust their savings and increase other forms of debt, like credit card debt.

“When people struggle to access affordable health care, the effects ripple through our economy,” said Sheldon Weisgrau, foundation vice president of Health Policy and Advocacy, in a press release.

“It’s not just about health; it’s about financial stability, workforce productivity, and the ability of families to thrive,” he added.

The foundation commissioned a statewide survey of over 2,000 adults last spring, conducted by the research firm SSRS. Data were weighted to be representative of the population.

The survey found Hispanic and Black Missourians are more likely to have medical debt compared to white adults. 

Those in rural areas are also more likely to have current or recent medical debt, as are those with disabilities.

Half of Missouri adults have held medical debt at some point in the last five years, according to the report. Most of them — 78% of those under age 65 — had health insurance at the time they received the care that sent them into debt.

One reason those with coverage are incurring debt, the report notes, is that many have unaffordable deductibles — meaning out-of-pocket costs they must pay before the insurance company starts to pay. Cost-sharing measures, like copays, can also be high.

In 2023, the average family deductible in Missouri was $3,783, according to the nonprofit KFF. The average deductible for single coverage in Missouri was $2,340.

Yet many Missourians live paycheck to paycheck. 

Four in ten Missourians don’t have the money to pay for an unexpected $500 bill, the Missouri Foundation for Health survey found. 

“The burden of medical debt is not only financially devastating but also demoralizing for families,” said Samantha Schrage Bunk, MFH health policy strategist, in the press release.

The results in the survey were similar to the national average found in a 2022 survey conducted by the nonprofit KFF.

The states with the worst rates of medical debt haven’t expanded Medicaid, KFF has found. Missouri implemented Medicaid expansion in October 2021.

There has been increasing attention to medical debt at the state and federal level in the last few years. At least 17 states this year proposed legislation related to consumer relief for medical debt, though not Missouri, according to LexisNexis’ state legislative tracker.

The Missourians surveyed widely support policies that would require greater price transparency, limits for hospital charges and uniform criteria for financial assistance programs.

“Missourians are clear – they want policy changes that make health care affordable and accessible, and they’re looking for government and health care systems to listen to them and take action today,” Schrage Bunk said.

In an earlier report, published in March, Missouri Foundation for Health interviewed focus groups.

“[Medical debt is] something that I will have to pay for the rest of my life,” one low-income woman, who has between $1,000 and $2,500 in debt is quoted as saying.

Others quoted needed to declare bankruptcy due to medical debt, or took hits to their credit that hurt their ability to find housing and employment.

One rural farmer needed to take on odd jobs in town to try to pay off thousands in debt. A man with disabilities needed to pay hundreds each month for years, instead of saving for retirement. A young mother needed to cut back on spending for food and clothes for her kids to pay hospital bills. 

Another described the “vicious cycle” of taking out credit card debt to try to pay off medical debt. 

“Honestly, if you’re middle class or low class,” one interviewee asked, “how can you afford $2,000 a ride in an ambulance?” 

Attendees cheer during a Missourians for Constitutional Freedom rally after the campaign turned in more than 380,000 signatures for its initiative petition to enshrine abortion rights in Missouri’s constitution Friday morning (Annelise Hanshaw/Missouri Independent).

Four lawsuits. Several failed attempts to raise the threshold to pass constitutional amendments. One unprecedented attempt to decertify a ballot measure. 

Despite this succession of failed GOP efforts to torpedo Amendment 3 over the past 18 months, abortion will remain on Missouri’s Nov. 5 ballot. 

“What a long strange trip it’s been,” said Michael Wolff, a former Missouri Supreme Court chief justice and dean emeritus at St. Louis University School of Law, quoting Grateful Dead guitarist Jerry Garcia. 

In the 18 months since the amendment, which would legalize abortion up until the point of fetal viability, was proposed as an initiative petition, it has faced a “minefield of ballot litigation” that ended earlier this month when the state’s highest court ruled the measure must stay on the ballot, Wolff said.

On June 24, 2022, Missouri became the first state in the country to ban abortions in response to the U.S. Supreme Court striking down Roe v. Wade and the constitutional right to an abortion. The ruling triggered a state law banning all abortions with limited exceptions in cases of medical emergencies. There are no exceptions for victims or rape or incest. 

Since then, citizens in six states have voted to protect or increase abortion access, including in Kansas, Ohio and Michigan. Missouri is among 10 states where abortion will be on the ballot this year. 

Amendment 3 would legalize abortion until the point of fetal viability and protect other reproductive rights, including birth control.

For anti-abortion lawmakers, “this is like the mega Super Bowl,” said James Harris, a longtime Republican political consultant.

He said litigation to drive up costs for proponents is advantageous, so lawsuits are par for the course. But the secretary of state’s effort to decertify the measure before the court cases concluded was unique.

While all the attempts were ultimately rebuffed by Missouri’s higher courts, they could foreshadow fights to come if Amendment 3 passes.

Sean Nicholson, a long-time progressive activist who has worked on multiple initiative petition campaigns, but is not involved with Amendment 3, called a circuit court ruling earlier this month that threatened to throw the measure off the ballot “some creative lawyering.”

“Nothing shocks me anymore in terms of what politicians are willing to do,” Nicholson said. “I think fundamentally they are terrified of a straight up or down vote on Amendment 3 and they’re going to pull out everything they can to avoid the consequences of voters having their say.”

State Sen. Mary Elizabeth Coleman, a Republican from Arnold, is among the anti-abortion activists who sued to keep Amendment 3 off the ballot. She said regardless of what happens in November, there’s a long road ahead.

“This is not the end all be all,” Coleman said. “And I think you will see efforts, win or lose, for Missourians to get another say in this.” 

In the courts

In March 2023, 11 iterations of what’s now Amendment 3 were filed by Dr. Anna Fitz-James on behalf of the coalition behind the campaign. The political maneuvering by the state’s Republican elected officials aimed at keeping the abortion-rights amendment off the ballot began almost immediately.

Missouri Attorney General Andrew Bailey refused to accept State Auditor Scott Fitzpatrick’s fiscal note summary estimating the potential public cost of the amendment. Bailey, who thought the estimate  should be about $6.9 trillion, attempted to force Fitzpatrick to alter his estimate of $51,000.

By the time Cole County Circuit Judge Jon Beetem ordered Bailey to certify the measure with Fitzpatrick’s estimate, the initial certification process, which is supposed to take no more than 54 days, had already taken nearly double that. The Supreme Court ultimately ruled in favor of Fitzpatrick.

Shortly after, Amendment 3 backers sued Secretary of State Jay Ashcroft over the ballot summary language he drafted, which would have asked Missourians, in part, if they wanted to “allow for dangerous, unregulated, and unrestricted abortions, from conception to live birth.” 

Beetem ruled in September 2023 that Ashcroft’s language was “problematic” and inaccurate. 

Missourians for Constitutional Freedom, the campaign behind the amendment, officially kicked-off signature gathering efforts in January, blaming the previous months of litigation for the delay. 

Despite a May deadline to gather more than 171,000 signatures from Missourians across six of the eight congressional districts, the campaign ultimately filed more than 380,000 signatures with the secretary of state’s office. 

This was despite a “decline to sign” campaign, the distribution of fliers urging Missourians to withdraw their signatures and unsubstantiated warnings that signing the initiative could result in identity theft. 

At the same time, GOP lawmakers failed to pass one of their top priorities — legislation raising the threshold to pass initiative petitions — due in part to a record-breaking filibuster by Senate Democrats.

Chris Melody Fields Figueredo, executive director at the Ballot Initiative Strategy Center, said Missouri has been a battleground for attacks on the initiative process. 

“We’ve seen an escalation of attacks to the ballot measure process and politicians trying to change the rules of the game to prevent citizens from putting these issues on the ballot,” she said. “Like reproductive freedom.”

Shortly after Ashcroft certified the measure for the ballot in mid-August, he posted “fair ballot language” to his official website that mirrored the ballot language rejected by the courts in 2023. Cole County Circuit Judge Cotton Walker ruled the description was “unfair, inaccurate, insufficient and misleading.” 

Ashcroft was ordered to replace his language with the court’s language. 

The final effort to keep Amendment 3 off the ballot began in late August, when a lawsuit filed by anti-abortion lawmakers and activists claimed the initiative petition failed to follow a number of laws. 

Cole County Circuit Judge Christopher Limbaugh sided with the plaintiffs, ruling the proposal failed “to include any statute or provision that will be repealed, especially when many of these statutes are apparent.”

“I do think the circuit court decision is an important inflection point for the legislature to have a policy discussion in [2025] about when all of these measures are putting umpteen things into the constitution which then directly or indirectly invalidate a statute,” James said. “Should the voter clearly know that, and has it been kind of loosy-goosy?”

The Supreme Court took an expedited appeal of Limbaugh’s ruling. But Ashcroft announced he was decertifying the measure, an unprecedented attempt to rescind his previous decision that the measure had met the requirements to be on the ballot.

The next day, the Supreme Court judges said Ashcroft missed his statutory deadline to change his mind and they allowed the measure to stay on the ballot in a narrow 4-3 vote.

“The litigation, although highly charged, tends to wring out the politics of it and get down to what is legally required and how to apply that,” Wolff said, later adding: “It’s still not going to be easy to pass a constitutional amendment in the future, but I think we have some greater clarity about the process going forward.”

Alice Clapman, senior counsel for voting rights at the Brennan Center for Justice — a nonpartisan nonprofit that focuses on democracy issues — said Ashcroft “acted outside the law” when he decertified the ballot initiative.

It was an example of a series of “particularly brazen” attempts to stop abortion ballot initiatives that reflect a much broader pattern seen across the United States, she said. 

“In a way these tactics to block abortion rights ballot initiatives are really doubling down on the repressive nature of abortion restrictions,” Clapman said. 

Ashcroft called Clapman’s characterization of him “patently false,” saying his decision was within reason until the Supreme Court decided otherwise.

“The court did not follow state statute to stop it from going to the ballot,” he said. “I stepped in and did what the court illegally failed to do.”

Ashcroft added that he was “disheartened” by the rulings, but he expects if Amendment 3 passes, “some people will celebrate, and some people will act in the very same way they did in 1973 when Roe v Wade passed. They will work and act to make sure that women and children are protected.”

Missouri isn’t the only state to have a fight over an abortion amendment play out in new ways. 

In Florida, state police have knocked on voters’ doors to question them about signing a petition to restore abortion rights in their state. A state health care agency also created a website denouncing the amendment, and Florida Gov. Ron DeSantis has been particularly vocal in his opposition to it.

In Arkansas, the state Supreme Court upheld the secretary of state’s decision to keep an abortion amendment off the ballot, ruling that the campaign behind the initiative did not submit the correct paperwork on time.

If voters approve Amendment 3, Missouri could be the first state to overturn a statewide ban by the vote of the people. 

2 years after Missouri banned abortion, navigating access still involves fear, confusion

GOP lawmakers over the last decade passed laws targeting abortion providers in order to make obtaining an abortion more difficult. Those laws included mandatory pelvic exams for medication abortions and 72-hour waiting period between the initial appointment and an abortion.

A decade ago, more than 5,000 abortions were performed in the state, according to data from the Missouri Department of Health and Senior Services. But by 2020, that number dropped to 167 as providers closed. Between the Supreme Court decision in June 2022 through March 2024, there were 64 abortions under the state’s emergency exemption, according to data from the Missouri Department of Health and Senior Services. 

Meanwhile, a recent study by the Guttmacher Institute, a reproductive rights research group, found that in 2023, 8,710 Missourians traveled to Illinois and 2,860 Missourians went to Kansas for the procedure, which remains legal in both states. 

What’s next

Polling has remained favorable for Amendment 3. 

An Emerson College poll found 58% of those surveyed support Amendment 3, with 30% opposed. The most recent SLU/YouGov Poll found that 52% supported the amendment and 34% opposed.

State Sen. Tracy McCreery, a Democrat from Olivette and a long-time advocate for abortion rights, said it’s important to keep in mind Missouri’s recent past.

“The legislature has a history of overturning the vote of the people,” she said.

As far back as 1940, when Missourians approved an initiative for a nonpartisan court plan to select appellate judges, the legislature put a proposition on the ballot two years later hoping to repeal it. Voters rejected the attempt. 

In 2010, voters approved a new statute banning puppy mills by regulating dog breeders. The next year, legislation changed key provisions, such as removing the cap on the number of dogs allowed per breeder, undoing the citizen-led statutory change.

In 2018, Missourians passed a citizen-led amendment that would have required legislative districts be drawn to ensure partisan fairness. This amendment, known as “Clean Missouri,” was repealed two years later through a legislature-proposed amendment.

In 2020, Missouri voters approved Medicaid expansion. Lawmakers refused to fund it until the Missouri Supreme Court ruled they had no choice. 

If Amendment 3 passes, McCreery predicted, Republican lawmakers will try something similar to what happened with Medicaid expansion, “but on steroids.”

“I expect shenanigans moving forward,” she said.

Wolff said lawmakers may also attempt to legislate around the issue. Even though parental consent is not directly mentioned in the amendment, lawmakers could try to rewrite laws requiring it. 

Wolff added that he’s never seen such a unified effort by elected officials to stop a ballot measure. Even the heavily-opposed embryonic stem cell research amendment of 2006 didn’t face such pushback.

But lawmakers limited the kinds of research that could be conducted under the stem cell amendment. Ultimately, those restrictions made it impossible for researchers to move forward. 

“(Amendment 3) is going to be harder to chip around about,” Wolff said. “But they’ll be creative. They’ve already been quite creative, so they will continue. That’s what a democratic republic will give you.”

Coleman said if the amendment passes, it will not be the last time Missourians vote on abortion, adding that an effort similar to the one that undid Clean Missouri is likely. 

“The reason why you’ve seen such passion in the pro-life movement or from elected officials who are pro-life is because that reflects the passion of Missouri citizens who are pro-life,” Coleman said. “Which is to do anything and everything to protect the most vulnerable.”

Wolff agreed that this won’t be the end. 

“There’s nothing permanent,” Wolff said, “in the people’s constitution.”

The Cole County Courthouse is hosting a trial challenging the state's restrictions on gender-affirming care, bringing in a judge from Wright County to oversee the bench trial (Annelise Hanshaw/Missouri Independent).

A case that will determine whether Missouri can continue restricting adolescents’ access to gender-affirming care began Monday in Cole County Circuit Court.

The plaintiffs — which include transgender minors, gender-affirming care providers and loved ones — will argue that medical treatments for gender dysphoria are “safe and effective,” attorney Omar Gonzalez Pagan said in opening arguments.

The state will defend the 2023 law restricting gender-affirming care by looking into the risks of the treatment and highlighting those who have regretted medical transitions.

“These kids need compassionate, evidence-based medicine. But what they’ve been doing for the past 15 years isn’t evidence-based,” Solicitor General Joshua Divine said in his opening statement.

Defendants include Gov. Mike Parson, who signed the bill into law, and Attorney General Andrew Bailey, who is responsible for enforcing the law.

Both parties plan to call a host of expert and fact witnesses, and attorneys have requested a week for each side to present evidence.

On the first day of the trial, which will be heard by Circuit Judge Craig Carter without a jury, attorneys argued over which experts were most qualified to speak on the efficacy and risks of gender-affirming care.

“(Plaintiffs’ experts) are the type of people that are qualified to testify as to this type of care,” Gonzalez Pagan said. “The state’s experts, with one exception, do not have this sort of experience.”

Divine said that plaintiffs’ experts benefit financially from gender-affirming care, so they have their “financial reputations” at stake. He defended his witnesses’ qualifications, calling one a “victim of cancel culture” when a journal article was retracted.

The first expert called to testify was Dr. Aron Janssen, vice chair of clinical affairs at the Pritzker Department of Psychiatry and Behavioral Health at Lurie Children’s Hospital in Chicago. A majority of the patients in his psychiatry practice are transgender or gender-nonconforming children and adolescents, he said, and he has published approximately 24 articles in academic journals.

Jason Orr, an attorney for the plaintiffs, asked him about the state’s claims.

One claim is that gender dysphoria is a self-diagnosed condition because the symptoms are self-reported. Janssen said physicians base a diagnosis on questions to patients and loved ones, like other psychiatric conditions he treats.

“If that was a standard to base diagnosis, we wouldn’t have depression, anxiety, migraines,” he said.

The state will bring “detransitioners,” or people who began transitioning to a gender other than their sex as assigned at birth and later stopped. One received gender-affirming care in Missouri as an adult, but none received the care as a minor in Missouri, attorneys discussed in a virtual hearing last Friday.

Orr asked Janssen if there’s any scientific literature about those who stop their transition.

“The majority of patients who detransition do so because of external pressures but not because of internal pressures or regret,” Janssen said. “For some, transition is a wonderful experience… For others, it means you are kicked out of your family, lose your job.”

Patrick Sullivan, with the attorney general’s office, used several documents to challenge Janssen during cross-examination. Some were not on the list of items the defense plans to submit as evidence, but Carter allowed the exhibits for questions only.

Some of the documents were studies, including the over 400-page Cass Review published earlier this year. The report was a systematic review commissioned in England that concluded that there was weak evidence to support cross-sex hormones and puberty blockers for transgender youth.

Sullivan presented Janssen a document called an “evidence pyramid,” with systematic reviews at the top as the best form of scientific literature.

Janssen said the Cass Review had a key flaw: the authors are not experienced in gender-affirming care and wouldn’t know the best factors to look at.

“When we look at what is involved in creating a good systematic review, having experience in the field is important,” he said. “When none of the authors work in the area, we have to take what they’re saying with a grain of salt.”

Sullivan interrupted him as Janssen explained the review’s flaws.

“He’s answering your question,” Carter said.

Sullivan’s questioning lasted around two hours, with multiple objections from plaintiffs as new exhibits came into the courtroom. The exhibits were largely studies out of Europe and articles from The New York Times and The Free Press.

Sullivan used an opinion article to question plaintiffs’ second expert, a clinical child psychologist.

The other witness to take the stand during the trial’s premiere day was a transgender man who transitioned at a young age in Missouri.

Arguments are scheduled to conclude Oct. 4.

The Missouri Supreme Court takes the bench on Sept. 10, 2024, in Jefferson City to hear a case questioning whether an amendment to overturn the state's abortion ban will remain on the state's November ballot. From left are Judges Kelly C. Broniec, Robin Ransom, W. Brent Powell, Chief Justice Mary R. Russell, Zel. M. Fischer, Paul C. Wilson and Ginger K. Gooch (Pool photo by Robert Cohen/St. Louis Post-Dispatch).

The decision to keep a constitutional amendment legalizing abortion on the November statewide ballot was decided by a narrowly-divided Missouri Supreme Court, according to opinions released Friday.

The majority opinion was written by Judge Paul Wilson, with Chief Justice Mary Russell, Judge Robin Ransom and Judge Brent Powell concurring. 

The dissent was authored by Judge Kelly Broniec, with Judge Zel Fisher and Judge Ginger Gooch concurring in the dissent.

Amendment 3, if approved by a simple majority, would legalize abortion up until the point of fetal viability and protect other reproductive rights, including birth control. Abortion is illegal in Missouri with limited exceptions for medical emergencies. There are no exceptions for victims or rape or incest. 

The Supreme Court, while divided, made one point clear in both the majority and dissenting opinions: “this case is not about abortion.”

“It concerns only what information the constitution requires proponents to include on any initiative petition,” Wilson wrote in the majority opinion. “It is about form and procedure, not substance.”

Wilson was appointed to the court by then-Democratic Gov. Jay Nixon. Russell was appointed by former Democratic Gov. Robert Holden. Powell was appointed by former Republican Gov. Eric Greitens, and Ransom was appointed by current Republican Gov. Mike Parson

Broniec and Gooch were appointed by Parson, and Fisher was appointed by Republican Gov. Matt Blunt.  

Both Gooch and Broniec are up for retention elections this year.

The initial case stemmed from a lawsuit filed in late August by a group of anti-abortion lawmakers and activists claiming the initiative petition that was later certified and approved as an amendment, failed to follow a number of laws. 

This includes a section of state law requiring initiative petitions “include all sections of existing law or of the constitution which would be repealed by the measure.”

The plaintiffs — state Sen. Mary Elizabeth Coleman, state Rep. Hannah Kelly, anti-abortion activist Kathy Forck and shelter operator Marguerite Forrest — sued Secretary of State Jay Ashcroft arguing the initiative petition failed to state any laws that would be repealed if it passed. 

Attorneys for Missourians for Constitutional Freedom, the campaign behind the ballot measure, have said the amendment would not repeal the state’s current abortion law or take it off the books. Instead, they told the courts, it would create a new law that would supersede much of the existing one because not every element of the current law would be rendered moot, including laws protecting women who get abortions from prosecution. 

They also argued anything that falls under the scope of the amendment would be left to the judicial system to interpret and not truly repealed just in the amendment’s passing.

More than 800 Missouri medical professionals sign letter in support of abortion amendment

A majority of the Supreme Court ruled that interpreting the law to require listing every possible provision that could be impacted by an amendment would have “absurd effects.” 

“It seems reasonable to expect that few – if any – initiative petitions could survive under such a statute,” Wilson wrote.

He added that to interpret the statute as such would be unconstitutional because it would impede citizens’ right to the initiative petition process. 

“In fact,” Wilson wrote, “it is hard to imagine how a statute could impair and impede the initiative process more.”

Broniec, in her dissent, took a broader interpretation of the word “repeal,” saying that it is also defined as the ability to “effectively render invalid.”

She called the majority opinion “an absurd result contrary to the plain language” of the state constitution.

If Amendment 3 passes, Broniec wrote, Missouri’s current abortion ban cannot continue to stand. She noted a handful of other current laws that could be in conflict with the amendment, including parental consent for minors and the mandatory 72-hour waiting period between meeting with a doctor and receiving an abortion. 

“Today’s opinion from the Missouri Supreme Court was a complete rejection of the anti-abortion politicians’ arguments and attempts to subvert our constitutional right to vote to protect reproductive freedom,” Tori Schafer, an attorney with the ACLU of Missouri, said in a statement Friday. “Including access to abortion, birth control and miscarriage care.”

Coleman, one of the plaintiffs, wrote on social media Friday that she agreed the issue at hand wasn’t abortion.

“It is about abrogating the will of the general assembly,” Coleman wrote. “By using absurd arguments to reach their desired result.”

Mary Catherine Martin, an attorney with the Thomas More Society who represented the plaintiffs, said in a statement Friday that she still believes the crafters of the initiative petition violated state laws.

“It should not require courage to clearly apply the law, but it does when powerful political forces oppose a just outcome,” Martin said. “We applaud the courage of these three dissenting judges.”

The Supreme Court published its decision on Aug. 10, a few hours after oral arguments were completed and less than three hours before the constitutional deadline to remove a question from the ballot. 

In their decision, the majority reversed a lower court ruling made just four days earlier by Cole County Circuit Judge Christopher Limbaugh, who recommended the measure be stripped from the Nov. 5 ballot. 

As part of its decision, the Supreme Court ordered that Ashcroft “certify to local election authorities that Amendment 3 be placed on the Nov. 5, 2024, general election ballot and shall take all steps necessary to ensure that it is on said ballot.” 

A day earlier, Ashcroft, in an unprecedented move, attempted to decertify the ballot measure based on the lower court’s ruling, and temporarily removed Amendment 3 from the Secretary of State’s website.

Correction: This story was updated at 4:10 p.m. to clarify that Chief Justice Mary Russell was appointed by former Democratic Gov. Bob Holden.

Clinics in states where most abortions are legal, such as Kansas and Illinois, are reporting an influx of inquiries from patients hundreds of miles away — and are expanding in response. Despite the Supreme Court’s overturning of federal protections in 2022, abortions are now at their highest numbers in a decade (Oona Zenda/KFF Health News).

Soon after a series of state laws left a Planned Parenthood clinic in Columbia, Missouri, unable to provide abortions in 2018, it shipped some of its equipment to states where abortion remained accessible.

Recovery chairs, surgical equipment, and lighting from the Missouri clinic — all expensive and perfectly good — could still be useful to other health centers run by the same affiliate, Planned Parenthood Great Plains, in its three other states. Much of it went to Oklahoma, where the organization was expanding, CEO Emily Wales said.

When Oklahoma banned abortion a few years later, it was time for that equipment to move again. Some likely ended up in Kansas, Wales said, where her group has opened two new clinics within just over two years because abortion access there is protected in the state constitution — and demand is soaring.

Her Kansas clinics regularly see patients from Texas, Missouri, Oklahoma, Arkansas, and even Louisiana, as Kansas is now the nearest place to get a legal abortion for many people in the southern U.S.

Like the shuffling of equipment, America’s abortion patients are traveling around the nation to navigate the patchwork of laws created by the Supreme Court’s Dobbs v. Jackson Women’s Health Organization decision, which left policies on abortion to the states.

Since that ruling, 14 states have enacted bans with few exceptions, while other states have limited access. But states that do not have an abortion ban in place have seen an 11% increase in clinician-provided abortions since 2020, according to the Guttmacher Institute, a national nonprofit that supports abortion rights. Over 170,000 people traveled out of their own state to receive abortion care in 2023, according to the institute.

Not all of the increase in abortions comes from interstate travel. Telehealth has made medication abortions easier to obtain without traveling. The number of self-managed abortions, including those done with the medication mifepristone, has risen.

And Guttmacher data scientist Isaac Maddow-Zimet said the majority of the overall abortion increase in recent years came from in-state residents in places without total bans, as resources expanded to improve access.

“That speaks, in a lot of ways, to the way in which abortion access really wasn’t perfect pre-Dobbs,” Maddow-Zimet said. “There were a lot of obstacles to getting care, and one of the biggest ones was cost.”

Last year, the estimated number of abortions provided in the U.S. rose to over 1 million, the highest number in a decade, according to the institute.

Still, abortion opponents hailed an estimated drop in the procedure in the 14 states with near-total bans.

“It’s encouraging that pro-life states continue to show massive declines in their in-state abortion totals, with a drop of over 200,000 abortions since Dobbs,” Kelsey Pritchard, a spokesperson for Susan B. Anthony Pro-Life America, wrote in a statement.

Organizations in states where abortion remains legal feel the ripples of every new ban almost instantly. One Planned Parenthood affiliate with a clinic in southern Illinois, for example, reported a roughly 10% increase in call volume in the two weeks following the enactment of Florida’s six-week abortion ban in May. And an Illinois-based abortion fund, Midwest Access Coalition, experienced a similar pattern the day the Dobbs decision was announced in June 2022.

“Our hotline was insane,” said Alison Dreith, the coalition’s director of strategic partnerships.

People didn’t know what the decision meant for their ability to access abortions, Dreith said, including whether already scheduled appointments would still happen. The coalition helps people travel for abortions throughout 12 Midwestern states, four of which now have total bans with few exceptions.

After serving 800 people in 2021, the Midwest Access Coalition went on to help 1,620 in 2022 and 1,795 in 2023. Some of that increase can be attributed to the natural growth of the organization, which is only about a decade old, Dreith said, but it’s also a testament to its work. It pays for any mode of transportation that will get clients to a clinic, including partnering with another Illinois nonprofit with volunteer pilots who fly patients across state lines on private flights to get abortions.

“We also book and pay for hotel rooms,” Dreith said. “We give cash for food, and for child care.”

The National Network of Abortion Funds, a coalition of groups that offer logistical and financial assistance to people seeking abortions, said donations increased after the Dobbs decision, and its members reported a 39% increase in requests for help in the following year. They financially supported 102,855 people that year, including both in-state and out-of-state patients, but have also seen a “staggering drop off” in donations since then.

Increased awareness about the options for abortion care, spurred on by an increase in news stories about abortion since the Dobbs decision, may have fueled the rise in abortions overall, Maddow-Zimet said.

Both sides now await the next round of policy decisions on abortion, which voters will make in November. Ballot initiatives in at least 10 states could enshrine abortion rights, expanding access to abortions, including in two states with comprehensive bans.

“Lives will be lost with the elimination of laws that protect more than 52,000 unborn children annually,” wrote Pritchard of Susan B. Anthony Pro-Life America, citing an analysis on the group’s website.

In the meantime, Wales said her clinics in Kansas don’t have enough appointments to accommodate everyone who reaches out about scheduling an abortion. In the early days after the Dobbs decision, Wales estimated, only 20% of people who called the clinic were able to schedule an abortion appointment.

The organization has expanded and renovated its facilities across the state, including in Wichita, Overland Park, and Kansas City, Kansas. Its newest clinic opened in August in Pittsburg, just 30 miles from Oklahoma. But even with all that extra capacity, Wales said her group still expects to be able to schedule only just over 50% of people who inquire.

“We’ve done what we can to increase appointments,” Wales said. “But it hasn’t replaced what were many states providing care to their local communities.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

After pharmacist walkouts last year, CVS Pharmacy officials said they added staff to help alleviate customer waits (Scott Canon/The Beacon).

A year ago this week, 27 pharmacists walked off their jobs in and around Kansas City to protest understaffing, low technician pay and burdensome workloads at some CVS-owned pharmacies.

Their action forced about a dozen Kansas City-area pharmacies and 10 others in outlying areas to close anywhere from a few hours to two full days. It inspired walkouts at CVS, Walgreens and Rite Aid pharmacies across the country later last fall.

And it sparked a nascent labor movement that is undertaking a national store-by-store campaign.

“We had no idea what we were starting,” said Ed Smith, a former CVS pharmacist who organized the walkouts. “We were just fed up with our situation.”

Experts say the industry was ripe for an uprising.

Economic pressures, transformed buying habits and a worldwide pandemic have forced retail pharmacies to shut down, left pharmacists with overwhelming workloads and put regulators on guard against mistakes in your prescriptions.

Kansas City’s walkout and the wave of news coverage that came with it simply offered a jump start.

‘Go, go, go’ working conditions for pharmacists

The Kansas City pharmacists complained last year that CVS wasn’t hiring enough pharmacists and pharmacy technicians, leaving them handling immunization appointments along with filling prescriptions, answering calls and dealing with customers.

On top of that, Smith said, pharmacists were assigned to help at the chain’s busiest stores but got no relief at their home stores. Smith had to go to a pharmacy in Blue Springs with a backlog of 3,000 prescriptions.

“There were not enough terminals and not enough work space,” he said. “There were drugs all over the floor. You couldn’t even find stuff. I’ve never seen a store in worse shape. Ever.”

In an emailed response to questions, Amy Thibault, a CVS spokeswoman, said that the company has brought in additional staff at that Blue Springs store, at 3201 South 7 Highway. She said the pharmacy has made “significant improvements” since last year and “is focussed on serving its patients in a timely manner.”

In response to last fall’s protests, Thibault said, CVS had hired more than 60 pharmacists in the Kansas City area, added “dozens” of pharmacy technicians and made other changes to ease workloads, like balancing some tasks between stores and directing patients to digital channels.

But chain pharmacies, which increasingly dominate the retail market, continue to face concerns about working conditions in some stores. When the COVID-19 pandemic put these stores on the front lines of testing and vaccinating patients, it only exacerbated the situation.

“Every company, whether it’s Walgreens or CVS or any other corporate chain pharmacy, tries to get as much productivity with as little hours allocated as possible,” said Shane Jerominski, the California pharmacist who co-founded The Pharmacy Guild, the fledgling labor union that is trying to organize pharmacists and pharmacy techs in stores around the country.

A 2022 survey by the Kansas Board of Pharmacy found that more than half of Kansas, Missouri, Oklahoma, Nebraska and Colorado pharmacists were struggling.

Of the roughly 1,000 pharmacists surveyed, half of whom worked for chains, only 37% said their workload-to-staff ratio allowed them to operate “in a safe and effective manner.”

Customers see it when they get stuck with long drive-thru waits or encounter lines inside stores that stretch into the potato chip aisle. And when getting a prescription filled requires waiting hours — or even days.

“Pharmacists used to be busy if they filled 200 prescriptions,” said John Yost, a pharmacist who co-founded Pharmacy of Grace, a charitable pharmacy in Kansas City, Kansas. “Now a lot of the big chains are filling 500 to 1,000 prescriptions a day.”

Workloads only got worse during the pandemic, said Russell B. Melchert, dean of the University of Missouri-Kansas City School of Pharmacy.

“We started to see community pharmacists leave large chain settings,” he said.

And with a shortage of pharmacists willing to take on those jobs — and a significant drop in the number of pharmacy school graduates — chains struggled to fill jobs.

As a result, some pharmacists say they have little time to counsel patients.

“It got to the point where there was no time to have any conversation with people,” said Nick Romo, who left a job at CVS two years ago to start Pharmington Drugs, an independent drug store in Overland Park. “It was just head down to the computer. Go, go, go.”

An evolving industry

CVS and Walgreens spent the 1990s and early 2000s buying up independent pharmacies and building brick-and-mortar stores. They wanted to capitalize on a rapid rise in the number of prescriptions Americans were getting, which came with an equally dramatic jump in prescription drugs on the market.

But the chains have spent recent years trimming costs, by reducing staff and closing stores, and leaning into new revenue streams.

They can make money when a pharmacist gives a vaccine, but they likely won’t make much when they sell a drug.

Industry experts said that’s where the difficulties arose for the pharmacists working at chain stores. To trim costs, they’ve cut staff. To fortify profits, they’ve added responsibilities.

“The chain pharmacies really did take a big hit to morale related to their staffing models,” said Jessica M. Bates, a clinical associate professor of pharmacy at the University of Kansas who has studied work satisfaction among pharmacists. “Lots of pharmacists are exploring other options for a career outside of that setting.”

Jillian Freeman, a pharmacy manager at a CVS in Liberty, said community pharmacists she knows just want to care for their patients. She said that the pharmacists who walked off the job last year were exaggerating problems. No matter which company pharmacists work for, she said in an interview arranged by CVS, they have faced added stress and pressure in recent years.

“You can go to any competitor and it’s the same situation,” Freeman said. “We’re facing going through COVID. We’re facing vaccines and supporting the community. … And there continues to be an uptick in medications.”

Fear of mistakes

Some pharmacists worry that the added responsibilities and pressures will lead to medical errors. So do regulators.

That led the Missouri Board of Pharmacy to adopt new rules in 2022 banning policies or procedures that could threaten patient safety.

The board’s April 2021 guidance statement had cautioned against  “any dispensing or vaccination metrics/requirements that place unreasonable expectations on pharmacy staff (e.g., # of prescriptions or vaccines per hour).”

And a December 2021 update to the statement, pointed to “an alarming number” of complaints still coming in about working conditions. They included pharmacies having “excessive” prescription backlogs and pharmacy staff not being given sufficient lunch or rest breaks and having to work extended stretches without days off.

Meanwhile, those workers now also handle vaccines and COVID testing, answer phones and manage a queue of drive-thru customers.

The Kansas Board of Pharmacy also has responded to a growing number of complaints about working conditions with rule changes. In July, the board passed rules that will require pharmacies to review a log of incidents — anything from medication dosage errors to patient information handling mistakes — more frequently. The review, meant to trigger changes so mistakes aren’t repeated, now must happen every two months instead of every three months.

“When concerns voiced by pharmacists began indicating a potential impact on patient safety,” said Alexandra Blasi, executive secretary of the Kansas board, “that is when the board became engaged and involved.”

There’s no clear data indicating that pharmacy errors are increasing. In most states, pharmacies have no obligation to report them to state regulators.

But last year, California’s Board of Pharmacy estimated that pharmacists in the state were making 5 million errors a year.

The Missouri Board of Pharmacy opened 507 complaints in fiscal year 2023 and took disciplinary action in 67 cases. One pharmacist license was revoked, two were voluntarily surrendered and 24 technicians were disqualified.

The Kansas Board of Pharmacy received 115 complaints in 2022. As a result of one of those complaints, the board ordered CVS to pay a $1,000 fine after an investigation found that its pharmacy at 12691 Antioch Road in Overland Park had supplied a patient with the wrong needles for her insulin. Instead of getting the prescribed eight units, the patient injected 10 times more because the needles were the wrong size.

The board noted in its order that the legally required internal report “was weak in preventative measures to ensure the prevention of the same type of incident from recurring.”

Labor takes a stand

After Kansas City’s walkout, Jerominski got serious about starting a union. Once The Pharmacy Guild got backing from IAM Healthcare, an arm of the International Association of Machinists and Aerospace Workers, Jerominski and other organizers launched a national campaign.

When their website first went up late last year, 30,000 people logged in all at once to fill out a labor union interest form, crashing the site.

Since, The Pharmacy Guild has led successful union elections at CVS Omnicare in Las Vegas and at CVS stores in Woonsocket and Wakefield in Rhode Island and a Walgreens in Vancouver, Wash.

Jerominski said more Pharmacy Guild union votes are on the horizon. That includes Kansas City stores, he said, although he declined to provide details. Labor unions are becoming more common across health care professions.

But the reality, said Gerald Friedman, a professor of economics at the University of Massachusetts at Amherst, is that organizing chain pharmacy stores will be an uphill battle.

“You’re going up against really large corporations,” he said. “You organize a few locations, and they ship those customers to mail order. You organize a few more locations, and they just close them down.”

Both CVS and Walgreens said in written statements that they respect their employees’ right to unionize.

The United Food and Commercial Workers Union already has a pharmacy branch that represents 20,000 CVS, Walgreens and Rite Aid retail and pharmacy workers. But The Pharmacy Guild is focusing solely on pharmacists, technicians, interns and residents.

Kansas City’s pharmacists were successful last fall partly because their walkout drew national news coverage. And in response, CVS sent Chief Pharmacy Officer Prem Shah to Kansas City to meet with the disgruntled employees.

Smith said those meetings gave him hope that something might change.

“I genuinely thought they would come in, fix the problems and we’d move on,” he said.

Smith still has the two-page memo he wrote just after an Oct. 13 meeting, detailing eight steps the company had agreed to take in response to pharmacists’ concerns. It included promises to limit the number of vaccines that stores had to give and increase the number of hours techs could work.

Smith ended his memo with clear optimism.

“CVS has taken the team here in KC very seriously and saw that we had legitimate ‘pain points’ that had to be addressed,” Smith wrote. “As I read through this list, more has been accomplished to improve our stores in the last 3 weeks than in the last 25 years.”

But his hope was short-lived.

Smith said the company canceled vaccine appointments at some Kansas City stores for a time. And it sent workers in from other markets to help stores get caught up on prescriptions. But Smith said everything at his store went right back to where it had been before the walkouts  — something CVS disputes.

Smith left CVS in January.

“They put a Band-Aid on a hemorrhage,” he said.

Now he’s a pharmacist at a Walmart in Atchison, Kansas. And he’s still working to organize pharmacy workers.

“Maybe something stronger (like a union) can help change the industry,” Smith said, “because we obviously did not.”

Correction: This story originally misstated when Shane Jerominski, a founder of The Pharmacy Guild, stopped working at CVS.

This article first appeared on Beacon: Missouri and is republished here under a Creative Commons license.

Scott Faber of the Environmental Working Group speaks Tuesday, Sept. 17, at a Capitol Hill briefing urging the EPA to ban the use of the herbicide paraquat dichloride to protect farmworkers (Ariana Figueroa/States Newsroom).

WASHINGTON — Public health advocates and farmworkers called for a federal ban on a toxic herbicide they say led to their Parkinson’s disease during a Tuesday briefing for congressional staffers.

The U.S. Environmental Protection Agency will determine next year if the herbicide, paraquat dichloride, should have its license renewed for another 15 years. The herbicide is used for controlling weeds in agriculture settings. It’s currently banned in more than 70 countries and has several serious health conditions it’s linked to, such as cancer and increases the likelihood of developing Parkinson’s disease.

Nora Jackson, a former farmworker of Indiana, said that her cousin, whose job it was to spray paraquat on farms, developed Parkinson’s at 55 years old. Signs of Parkinson’s usually appear around 60 years old.

“Farmworkers often have to do extremely risky jobs … but it doesn’t have to be that way,” Jackson said. “It is possible to have an agriculture system that does not depend so heavily on paraquat and it does not have to be a pesticide that puts so many people’s lives at risk.”

The disease has drastically affected his life, Jackson added.

“He now relies heavily on medication and uses a walking stick to be able to walk every day,” she said.

The briefing on the health risks of paraquat was hosted by the Michael J. Fox Foundation for Parkinson’s Research, Alianza Nacional de Campesinas, which is an alliance for farmworker women, and the Environmental Working Group, a nonprofit that produces research and advocates for public health.

The Michael J. Fox Foundation for Parkinson’s Research was established by the actor who starred in blockbusters Back to the Future, Doc Hollywood and Teen Wolf. Fox was diagnosed with early onset Parkinson’s at the age of 29.

Ban necessary

The EPA has until Jan. 17 to make a decision on paraquat’s future availability.

Advocates at Tuesday’s event called for the agency to deny paraquat’s license renewal, saying other regulations to reduce exposure to the herbicide have come up short.

“Keep in mind that people have been using this chemical as directed, and are still developing Parkinson’s disease,” Scott Faber, Environmental Working Group’s senior vice president of government affairs, said. “So putting more restrictions on how it’s used, when it’s used, what equipment you use, and so on, is not the answer.”

Parkinson’s disease affects the nervous system and causes unintended shakiness, trouble with balance and stiffness. There is no cure.

The California Legislature is moving to ban the herbicide. 

David Jilbert, of Valley City, Ohio, a former farmworker with a background in engineering, was diagnosed with Parkinson’s in 2021.

“As a longtime environmental engineer, I understood the importance of personal protection equipment, and I particularly followed all safety protocols,” he said.

He sold his vineyard in 2019 because he wasn’t feeling well and his hands were beginning to move slowly.

“My diagnosis changed everything, affecting every aspect of my life, from physical capabilities to emotional wellbeing, financial stability,” he said. “There is no cure for Parkinson’s. It is degenerative and it will only get worse, not better.”

Charlene Tenbrink of Winters, California, was diagnosed with Parkinson’s in 2020. She worked on her family farm from 1993 to 2000 where she would mix, load and spray paraquat.

Tenbrink said she felt let down by the federal government because she was unaware of the health risks that paraquat could pose.

“We’ve been trying to change this,” she said, “for a long time.”

Illinois Democratic Sen. Tammy Duckworth speaks about access to in vitro fertilization on the steps of the Capitol building on Tuesday, Sept. 17, 2024, along with other Senate Democrats holding photos of families who benefited from IVF. At right, Sen. Patty Murray, D-Wash., holds a photo of Duckworth’s family that includes Duckworth’s children, born with the help of IVF (Jennifer Shutt/States Newsroom).

WASHINGTON — The closely divided U.S. Senate gridlocked Tuesday over the best way to provide nationwide protections for in vitro fertilization, despite lawmakers from both political parties maintaining they want to do so.

Republicans voted against advancing a Democratic bill that could have prevented states from enacting “harmful or unwarranted limitations” on the procedure and bolstered access for military members and veterans. Two Republicans voted with Democrats — Maine’s Susan Collins and Alaska’s Lisa Murkowski.

That came just a short time after Senate Democrats — who narrowly control the chamber — in a procedural move blocked a GOP bill from Sens. Ted Cruz of Texas and Katie Britt of Alabama that would have barred Medicaid funding from going to any state that bans IVF.

The 51-44 vote that prevented Democrats’ legislation from moving toward a final vote followed numerous floor speeches and press conferences, including by the Harris-Walz presidential campaign, that sought to elevate the issue ahead of the November elections. The measure needed 60 votes to advance.

“This is a chance for my colleagues across the aisle to put their votes where their mouths have been,” said Illinois Democratic Sen. Tammy Duckworth, the bill’s sponsor and a mom of two children born as a result of IVF. “They say they support IVF. Here you go — vote on this.”

Duckworth said the legislation would provide critical IVF services to U.S. military members and veterans, many of whom experience infertility or experience difficulty having children due to their service.

“It allows our military men and women, prior to a deployment into a combat zone, to preserve and freeze their genetic material; so that should they come home with injuries that result in them becoming infertile, they will have already preserved their genetic material so that they can, themselves, start those beautiful families they wanted,” Duckworth said.

Vice President and Democratic presidential nominee Kamala Harris released a written statement following the vote rebuking GOP senators for blocking the bill.

“Every woman in every state must have reproductive freedom,” Harris wrote. “Yet, Republicans in Congress have once again made clear that they will not protect access to the fertility treatments many couples need to fulfill their dream of having a child.”

Republicans blocked Democrats’ bill earlier this year. But Senate leadership scheduled another vote after Republican presidential nominee Donald Trump reignited the issue in August when he said his administration would mandate health insurance companies pay for IVF — a significant break with how the GOP has approached the issue.

“We are going to be, under the Trump administration, we are going to be paying for that treatment,” Trump said during an interview with NBC News. “We’re going to be mandating that the insurance company pay.”

Alabama ruling

Democrats began speaking at length about preserving access to IVF earlier this year after the Alabama state Supreme Court issued an opinion in February that frozen embryos constitute children under state law.

That ruling forced all the state’s IVF clinics to halt their work until the state legislature passed a bill providing criminal and civil protections for those clinics.

Democrats have since argued that legislating the belief life begins at conception, which is championed by most conservative Republicans, is at odds with access to IVF, which typically freezes more embryos than would be implanted.

Those frozen embryos can be preserved or discarded, depending on the patient’s wishes, the clinic’s policies and state law. Some conservatives believe that discarding shouldn’t be legal or are opposed to the process altogether.

The Southern Baptist Convention, for example, voted earlier this year to oppose IVF, writing in a resolution that couples should consider adoption and that the process “engages in dehumanizing methods for determining suitability for life.”

“We grieve alongside couples who have been diagnosed with infertility or are currently struggling to conceive, affirm their godly desire for children, and encourage them to consider the ethical implications of assisted reproductive technologies as they look to God for hope, grace, and wisdom amid suffering,” it stated.

Senate Democrats’ press for IVF protections has gone hand-in-hand with their efforts to bolster other reproductive rights, like access to birth control and abortion.

The issues could play a significant role in determining the outcome of the presidential election this November as well which political party controls the House and Senate.

Republican vice presidential nominee and Ohio Sen. J.D. Vance missed Tuesday’s vote, but voted against advancing Democrats’ IVF bill when it was on the floor in June.

IVF bill from Cruz, Britt

Before the Senate held a vote on Democrats’ bill, Cruz asked for quick approval of an IVF bill he and Britt introduced earlier this year.

Washington state Democratic Sen. Patty Murray blocked his unanimous consent request.

During debate on that bill, Britt questioned why Democrats haven’t scheduled a recorded vote on her legislation, saying it could get the 60 votes needed to advance toward final passage.

“Today, we have an opportunity to act quickly and overwhelmingly to protect continued nationwide IVF access for loving American families,” Britt said. “Our bill is the only bill that protects IVF access while safeguarding religious liberty.”

The Britt-Cruz legislation has three co-sponsors, including Wyoming Sen. Cynthia Lummis, Kansas Sen. Roger Marshall and Mississippi Sen. Roger Wicker.

Murray said the Britt-Cruz bill didn’t address what would happen in states that legislate fetal personhood, which she called “the biggest threat to IVF.”

“It is silent on whether states can demand that an embryo be treated the same as a living, breathing person,” Murray said. “Or whether parents should be allowed to have clinics dispose of unused embryos, something that is a common, necessary part of the IVF process.”

Cruz tried to pass his legislation through the unanimous consent process, which allows any one senator to ask for approval. Any one senator can then block that request from moving forward — as Murray did. There is no recorded vote as part of the UC process.

Cruz previously asked for unanimous consent to pass the bill in June, but was blocked then as well.

Legal protections

Democrats’ 64-page bill would have provided legal protections for anyone seeking fertility treatment, including IVF, and for the health care professionals providing that type of care.

It would have barred state and federal governments from “enacting harmful or unwarranted limitations or requirements” on IVF access.

The legislation would have bolstered fertility treatment coverage for members of the military and veterans, as well as their spouses, partners, or gestational surrogates.

The American Society for Reproductive Medicine supports Democrats’ legislation. Chief Advocacy and Policy Officer Sean Tipton wrote in a statement released this week that Democrats’ IVF bill would “protect the rights of Americans to seek the medical services they may need to have children and ensure no healthcare provider faces legal consequences for trying to help their patients as they seek to build their families.”

“This legislation also increases access to IVF treatments for all Americans by mandating that employer-sponsored insurance plans and other public insurance plans cover fertility treatment,” Tipton wrote. “Significantly, it would ensure the federal government does right by its own employees by providing coverage for active-duty military, veterans, and civilian staff.”

Dr. Jennifer Smith, an OB-GYN in St. Louis, was among 800 Missouri medical professionals who signed a letter in support of Amendment 3, which would legalize abortion up to the point of fetal viability (Annelise Hanshaw/Missouri Independent).

Dr. Betsy Wickstrom says she’s still lacking clarity on what constitutes a medical emergency under Missouri’s abortion ban, despite the law having been in place for more than two years. 

In Missouri, health care providers who perform abortions not deemed necessary emergencies can be charged with a class B felony, which means up to 15 years in prison. Their medical license can also be suspended or revoked.

So Wickstrom, a high-risk obstetrician in Kansas City more than three decades into her career, must first consult a team of lawyers.

“When we have something that looks like it’s skirting the line and there’s a flicker of a heartbeat, but someone is desperately ill, sure I can call up the attorney,” she told reporters Monday. “But they’re not going to put the hospital’s licensure on the line. They’re going to say ‘you know, good thing you live next to Kansas.’”

Dr. Jennifer Smith, an OB-GYN in St. Louis, agreed. 

“I don’t think that many hospitals feel comfortable testing this law because the government hasn’t provided us any clarity on it,” Smith said. 

Wickstrom and Smith are among more than 500 physicians and more than 300 other medical professionals who signed a letter in support of Amendment 3. If approved by a majority of Missourians on Nov. 5, the amendment would overturn Missouri’s near-total abortion ban and legalize the procedure up until the point of fetal viability. 

Missouri became the first state to enact a trigger law banning abortion except for cases of medical emergencies following the fall of Roe v. Wade in June 2022. There are no exceptions for survivors of rape or incest.

“As a result, Missourians are being denied abortions and forced to continue life-threatening pregnancies, risking their health and lives,” the medical professionals wrote in a letter through the Committee to Protect Health Care. “Doctors can’t treat patients with heartbreaking pregnancy complications until they are on the brink of death. Otherwise, they could be put in jail.”

The situation in Missouri leaves pregnant patients with few options, the group of physicians contend.

“It forces many to leave the state to receive care,” the letter continues, “while others are forced to carry a pregnancy against their will. No one should ever have their health deteriorate or need to flee to receive care, nor should anyone have to carry a pregnancy against their will.”

Between June 2022 and March 2024, 64 abortions were performed in Missouri under the state’s emergency exemption, according to data from the Missouri Department of Health and Senior Services.

Missouri among worst states for women’s overall health, reproductive care, study finds

Wickstrom said she often has difficult conversations with women about growing their families — conversations made more difficult by the ban. 

She has patients diagnosed with cancer who were advised not to start chemotherapy while pregnant. And she has patients with heart disease who might not survive another pregnancy. 

“But can I do anything about that in Missouri?” Wickstrom said. “No. These are people that have to find their way out of the state to get life-saving care.” 

Smith, who has been an OB-GYN in eastern Missouri for more than 20 years, said the questions she’s hearing from patients now are unlike any she’s heard in the past. 

“People are very hesitant to start their families and expand their families in this environment,” she said. 

In the past two years Smith said she’s had men ask her to promise to save their partner before their baby if something were to go wrong during a wanted pregnancy. 

Patients planning their families face similar fears.

“Do you think that it’s safe to be pregnant here? What if I have an ectopic? What if I have a miscarriage?” Smith said she hears often from patients. “What if something’s wrong with the pregnancy? What if something’s wrong with me?”

Supporters of Amendment 3 celebrate on Tuesday, Sept. 10, 2024, on the steps of the Missouri Capitol after the state Supreme Court ruled the abortion-rights measure could remain on the ballot (Anna Spoerre/Missouri Independent).

Missouri’s campaign to legalize abortion has more than doubled its fundraising totals since it was approved for the ballot in mid-August, despite — and perhaps fueled by — a lawsuit that threatened to knock it off the Nov. 5 ballot. 

Missourians for Constitutional Freedom, the coalition behind what will appear on the ballot as Amendment 3, has raised more than $16 million since launching in January, according to reports filed with the Missouri Ethics Commission.

Of that, $9 million in donations greater than $5,000 were reported to the commission since the measure was certified for the ballot on Aug. 13. Campaigns are required to report any donations over $5,000 within 48 hours of receiving them. Reports totaling all donations and expenditures are due to the state each quarter. 

The two most well-established political action committees working to fight the amendment include Missouri Stands with Women, which has raised at least $200,000, and Missouri Right to Life, which has raised nearly $675,000 this election cycle.

The largest donations to Missourians for Constitutional Freedom have come from four out-of-state progressive nonprofits that are not required to disclose their donors and are also helping fund reproductive-rights campaigns in several states. 

As of Thursday, the Sixteen Thirty Fund based out of Washington D.C. donated $4.5 million to Missouri’s effort. That includes a $3.5 million check on Aug. 30 — the second largest single donation in Missouri this year. 

The Fairness Project, also based out of Washington D.C., has donated $2.9 million. Most of that money came on Aug. 23, when the organization cut a $2.1 million check to the campaign. 

Both nonprofits also contributed significant funds to the state’s 2020 Medicaid expansion initiative petition effort, which ultimately succeeded, and to the current ballot effort to raise the minimum wage and mandate paid sick leave.

The campaign also received $1 million from a nonprofit out of Washington D.C. listed as Open Source Action Fund, which is linked to an address for Open Society Action Fund. The nonprofit was founded by George Soros, a liberal billionaire.

On Thursday, a Virginia-based nonprofit called Global Impact Social Welfare donated $750,000.

Successful statewide ballot initiative campaigns are often multi-million dollar endeavors. 

Missouri Supreme Court rules amendment legalizing abortion will remain on ballot

“It is expensive, and in these places where we can do it, it is the least expensive pathway to restoring rights,” Kelly Hall, executive director of The Fairness Project, said at a panel discussion during the Democratic National Convention. “In Missouri, for example, it would take a lot more money to flip that legislature and to flip that gubernatorial seat … the best (return on investment) we can get is putting this on the ballot and appealing to those Missouri voters who do want this.”

In an interview with The Independent, Hall said The Fairness Project is both a leading funder and a coalition partner of Missourians for Constitutional Freedom. The coalition also includes the state’s Planned Parenthood affiliates, the ACLU of Missouri and Abortion Action Missouri. 

She said any assumption that they simply parachute money into states is false. 

“It is impossible for nonprofits like us who may have resources to bring to bear to achieve anything without a campaign that is grounded in grassroots support and the support of Missouri voters,” Hall said. 

The fact that the nonprofits helping bankroll the campaign don’t disclose their donors has become a point of attack from anti-abortion activists and lawmakers in Missouri. 

“There is going to be a massive effort — and by massive I mean to the tune of millions of dollars,” U.S. Sen. Josh Hawley said of the abortion ballot campaign at a conference last weekend in Missouri. “Already, George Soros and dark money groups have poured into this state almost $5 million to begin spending on this radical amendment.” 

Stephanie Bell, a spokeswoman for Missouri Stands with Women, blamed “out-of-state liberal groups” for boosting the abortion-rights campaign’s finances.

On Tuesday, after the Missouri Supreme Court reversed a lower court’s attempt to take Amendment 3 from the ballot, Lt. Gov. Mike Kehoe, the front-runner for governor, called the ballot measure “a deceptive effort by out-of-state interests.” The Missouri Republican Party called Amendment 3 “bankrolled by radical out-of-state interest groups.” 

Hall, with The Fairness Project, said she doesn’t usually push back on “dark money” criticisms. 

“If they want to focus on this rather than on the issue that Missouri voters care about, which is making sure that everyone in their state has access to lifesaving reproductive health care when they need it,” she said, “then that’s a misread on their part of what Missouri voters care most about.” 

The campaign has seen overwhelming support from across the state, collecting initiative petition signatures from every county and turning in more than 380,000 signatures to the Missouri Secretary of State’s Office in May.

While the top donors have come from out of state, the campaign has also raised several million dollars so far from Missouri individuals and organizations.

Planned Parenthood Great Plains and Planned Parenthood Great Rivers, which have clinics in Missouri, have donated more than $1.1 million. The ACLU of Missouri has donated more than $620,000, the Health Forward Foundation based in Kansas City donated $500,000 and Abortion Action Missouri has given more than $230,000.

The campaign stresses that the largest donor base remains Missourians affected by the ban. 

“Throughout the campaign, eight out of 10 online contributions have come from right here in Missouri,” Rachel Sweet, campaign manager for Missourians for Constitutional Freedom, said in a statement. “Underscoring the true grassroots nature of this movement.”

Sweet said that in the days following a Friday ruling by a Cole County circuit judge that threatened to remove Amendment 3 from the ballot, more than 2,400 Missourians donated a quarter million dollars to the campaign. 

If Amendment 3 passes by a simple majority in November, Missouri could become the first state to overturn an abortion ban by the vote of the people. It would also join several other states that successfully protected abortion-rights through citizen-led ballot campaigns since Roe v. Wade was overturned in June 2022. 

Abortion is illegal in Missouri, with limited exceptions for medical emergencies. The amendment would legalize abortion up until the point of fetal viability and protect access to other reproductive health care, like birth control. 

“It is truly the grassroots infrastructure in Missouri,” Kelly said. “And the leadership of in-state partners in every ballot measure campaign that advances to voters that we’ve been involved in that make it such an inspiring place to work.”

This story was updated at 12:22 p.m. to correctly state that The Fairness Project is based out of Washington D.C.

(Sandy Huffaker/Getty Images)

WASHINGTON — The U.S. Senate will vote for a second time next week on legislation from Democrats that would bolster support for in vitro fertilization, though it’s unlikely GOP lawmakers will reverse course from their previous opposition.

Senate Majority Leader Chuck Schumer announced the revote Thursday afternoon, saying he hopes that Republicans will join with Democrats to advance the measure toward final passage. The bill would ensure patients have access to in vitro fertilization.

“Republicans can’t claim to be pro-family on one hand, only to block pro-family policies like federal protections for IVF and the child tax credit,” Schumer said. “But that’s just what they did this summer and I hope we get a different outcome when we vote for a second time.”

The Senate last held a procedural vote on the bill in June, though it didn’t come close to the 60 senators needed to advance.

The 48-47 procedural vote was mostly along party lines with Maine’s Susan Collins and Alaska’s Lisa Murkowski breaking with Republicans to support moving forward with debate and a final passage vote.

Louisiana Republican Sen. Bill Cassidy argued against advancing the bill during debate, saying the legislation wasn’t necessary since no state currently barred IVF.

“Today’s vote is disingenuous — pushing a bill haphazardly drafted and destined to fail does a disservice to all who may pursue IVF treatments,” Cassidy said at the time.

Washington state Democratic Sen. Patty Murray spoke in support of approving the legislation, saying in June it shouldn’t be “controversial, especially if Republicans are serious about” supporting access to IVF.

“As we saw in Alabama, the threat to IVF is not hypothetical, it is not overblown and it is not fearmongering,” Murray said.

Alabama state legislators earlier this year had to provide criminal and civil protection to IVF clinics after the state Supreme Court ruled that frozen embryos constituted children under state law.

The opinion from Alabama’s justices temporarily led all IVF clinics within the state to close their doors to patients, wreaking havoc on couples hoping to start or grow their families through the complicated, emotionally draining and often expensive process.

The issue also has emerged in the presidential race, and was fought over in the Sept. 10 debate by the Democratic nominee, Vice President Kamala Harris, and the Republican candidate, former President Donald Trump.

A Missouri case marked the 14th person to contract highly pathogenic avian influenza, or H5N1, this year amid ongoing outbreaks among poultry and dairy cattle. The Veterinary Diagnostic Laboratory at Iowa State University tests samples from animals for viruses such as avian influenza (Photo courtesy of Veterinary Diagnostic Laboratory).

WASHINGTON — Public health officials are still trying to determine how a Missouri resident contracted bird flu without having any contact with infected animals, but said Thursday there is no evidence of human-to-human transmission taking place in small enclaves or in a more widespread manner.

The Missouri case marked the 14th person to contract highly pathogenic avian influenza, or H5N1, this year amid ongoing outbreaks among poultry and dairy cattle, though it marks the first time someone without contact to those animals was diagnosed with the virus.

Nirav Shah, principal deputy director at the Centers for Disease Control and Prevention, said on a call with reporters the “evidence points to this being a one-off case, and those do happen with novel influenza.”

“Thus far, we have not seen any evidence of unusual levels of influenza activity in the area where this individual resides,” Shah said during the hour-long briefing. “There have been no increases in the volume of visits to emergency departments for influenza and no increase in laboratory detections of influenza cases in Missouri more broadly.”

The state’s public health laboratory, he said, is subtyping all positive cases of Influenza A, following the CDC recommending ongoing detailed surveillance this spring.

The practice is how doctors and public health officials confirmed this case and would likely be how they diagnose any uptick in cases in the future in the “overwhelming” number states that are taking the extra step of subtyping, he said.

There are several types of influenza virus that are classified by the letters A, B, C and D. The viruses within the influenza A category are further categorized or subtyped based on the proteins hemagglutinin (H) and neuraminidase (N). There are at least 130 combinations of subtypes within Influenza A, according to the CDC.

“So here’s the bottom line, our influenza surveillance system is designed to find needles in haystacks,” Shah said. “And as this case and others show, it is working. And here, in this case, we found such a needle, but we don’t know how it got there.”

The Missouri patient, who has significant underlying medical conditions, was admitted to a hospital on Aug. 22 after presenting to health care providers with “acute symptoms of chest pain, nausea, vomiting, diarrhea and weakness,” according to the CDC. The patient is not being identified out of privacy concerns.

The Missouri Department of Health and Senior Services announced the diagnosis on Sept. 4, as did the CDC in a separate statement.

Missouri DHSS noted the patient had recovered and been sent home from the hospital, while the CDC pointed out that the state has reported cases of H5N1 in commercial and backyard poultry flocks this year.

The patient hadn’t been in contact with any livestock or poultry and didn’t indicate in a detailed questionnaire that they had consumed any food products, like raw milk, that could have potentially transmitted the virus.

Shah said on the call that public health officials are technically classifying this as a case of H5 and not H5N1 as they work to sequence the virus more fully, though that might not be possible.

The CDC has begun classifying the virus’ genetic sequence, but since the patient’s viral RNA levels were “extremely low” the agency may not be “able to generate a full flu genome, including the neuraminidase or the N part of the virus,” he said.

“We’re throwing everything we’ve got at this, but ultimately a full sequence may not be technically feasible because of the low concentration of viral RNA,” Shah said. “The data that we do have and that have been generated thus far show an H5 virus that is closely related to the (H5N1) virus circulating among dairy cows.”

The CDC, he said, is “continuing to look for evidence of genetic changes that would suggest, for example, an increased potential for spread.” None have yet been found.

Demetre Daskalakis, director of the National Center for Immunization and Respiratory Diseases at CDC, said the risk to the general public from bird flu remains low.

“We assess risk continuously with every case and with every sort of change, and we continue to look at it as low,” Daskalakis said. “If there are changes, we would reassess that risk in real time.”

While the CDC investigation is ongoing, Shah said the further out from the case public health officials get without seeing any new diagnosis, the less likely they become.

“We are beyond the typical 10-day window for transmission,” Shah said. “And so with each passing day, the likelihood of this being something that’s happening deep underwater goes down.”

State Rep. Deb Lavender, D-Manchester, speaks during debate on March 1, 2023, in the Missouri House (Tim Bommel/Missouri House Communications).

House Democrats on Wednesday made an unsuccessful push to override Missouri Gov. Mike Parson’s veto of $2.5 million in funding for oversight of the state’s nursing homes, with all but eight Republicans voting to sustain the governor’s action.

It is the second year in a row Parson has vetoed funding for nursing home oversight. 

State Rep. Deb Lavender, a Democrat from Manchester, led the effort, arguing that the money would make Missouri’s nursing home residents safer.

“There are complaints that are going unanswered,” Lavender said, adding that one-third of Missouri’s nursing homes have been found to have serious deficiencies.

The additional funding would have helped the state’s long-term care ombudsman program hire more staff to advocate for nursing home residents.

The ombudsman program is composed of staff and volunteers tasked with helping protect and advocate for the interests of nursing home residents. They often serve as liaisons between a resident and the facility when issues arise, investigating and resolving complaints. Ombudsmen can help ensure residents are able to go to the bathroom, take their medications and be fed on time, for instance.

Missouri has consistently had one of the lowest nursing home staffing levels in the country which can contribute to residents not receiving proper care. 

The motion to override Parson’s veto failed by a vote of 56 for and 81 against. All Democrats present voted for the override. All but eight Republicans voted against it. 

“We just wanted to bring voice to the lack of being able to care for our seniors,” Lavender said during a press conference after the vote, adding that it was “no surprise” that a Democrat asking to overrule the Republican governor failed. 

In the scope of a $50 billion state budget, Lavender said, the governor’s decision to strip out the $2.5 million “doesn’t make sense to me.”

“This is twice we put it in,” she said, “and the governor has taken it back out.” 

The state budget signed by Gov. Parson in June left $1.9 billion unspent. 

Parson wrote to lawmakers this summer explaining his veto  that “while this supports the important goal of helping seniors throughout the state, there is insufficient funding from the appropriated source to support this item.” 

Last year, his veto letter noted a general need to ensure a balanced budget and the “financial stability of Missouri.”

Republican state Rep Jim Kalberloh of St. Clair said during the floor debate he was voting against the override to respect that there is “a reason why they did this,” referring to the governor’s office’s veto, but that he supports the funding and wants the legislature to try again next year to pass it.

“We spend a lot of money on a lot of things,” Kalberloh said, “If we can’t protect our elderly and are disabled, then we can think about where our money is going.”

Democratic state Rep. Doug Clemens, of St. Louis responded to Kalberloh, saying: “It’s our job, our responsibility to reflect the needs of our constituency,” rather than the will of the governor. Clemens said he has senior constituents who would benefit from the ombudsman program having more resources.

“And I don’t think it’s worthwhile to let somebody wait another year for us to get our act together,” he said. “…This is a paltry sum compared to the rest of our budget.”

In a report from AARP last year, Missouri ranked 48th in the country for nursing home quality and 46th in nursing home staff levels and turnover.

The most recent federal staffing data, updated in July, showed Missouri residents receive 3.3 hours of daily care, on average. That’s below the federal standard going into effect in the next few years, and was second only to Texas for the worst in the country.

Lenny Jones, state director of the Service Employees International Union (SEIU) Healthcare Missouri, which represents nursing home staff, told The Independent in an interview the cut is a disservice to residents and workers, and many of the issues arise from low staffing.

“There should be more eyes on what’s going on in nursing homes, not less,” he said.“So the more opportunities for family members, for residents, to be able to contact the ombudsman and issues around that is important, because that’s really, in many cases, the only voice.” 

Marjorie Moore, executive director of VOYCE St. Louis, an advocacy group for long-term care residents, said she was “really disappointed” in the vote Wednesday but “gratified” that more legislators and Missourians broadly are becoming aware of the need for the program and issues in nursing homes.

“We’re calling on whoever may be governor next year and next year’s legislators to continue this fight and get this funding in,” she said, “because this is an issue that’s not going away in any way shape or form.”

Missouri will have an increasing population of older adults, she said, and “we’re only going to have more people who are going to need those advocates.”

Moore said, despite the state’s failure to bring resources to the level needed, people should know the program is still operating statewide and residents in every nursing home throughout Missouri can contact them with concerns. 

The Missouri Supreme Court takes the bench on Sept. 10, 2024, in Jefferson City to hear a case questioning whether an amendment to overturn the state's abortion ban will remain on the state's November ballot. From left are Judges Kelly C. Broniec, Robin Ransom, W. Brent Powell, Chief Justice Mary R. Russell, Zel. M. Fischer, Paul C. Wilson and Ginger K. Gooch (Pool photo by Robert Cohen/St. Louis Post-Dispatch).

Missourians will have the opportunity to vote to enshrine abortion in the state constitution this November, the Missouri Supreme Court ruled Tuesday.

In a decision published less than three hours before the constitutional deadline to remove a question from the ballot, the Supreme Court reversed a lower court’s ruling that recommended the measure be stripped from the Nov. 5 ballot.

Secretary of State Jay Ashcroft “shall certify to local election authorities that Amendment 3 be placed on the Nov. 5, 2024, general election ballot and shall take all steps necessary to ensure that it is on said ballot,” the judgment read.

The court has not yet issued an opinion.

“This fight was not just about this amendment—it was about defending the integrity of the initiative petition process and ensuring that Missourians can shape their future directly,” Rachel Sweet, campaign manager for Missourians for Constitutional Freedom, the campaign behind the amendment, said in a statement.

In a lawsuit filed late last month, a number of anti-abortion lawmakers and activists sued Missouri Secretary of State Jay Ashcroft for certifying Amendment 3 for the ballot.

The suit was brought forward by state Sen. Mary Elizabeth Coleman, state Rep. Hannah Kelly, anti-abortion activist Kathy Forck and shelter operator Marguerite Forrest who in a statement Tuesday said the Supreme Court “turned a blind eye” in its ruling.

“The fight continues against the vile forces who have no regard for innocent life,” they wrote.

On the eve of the Supreme Court hearing, Ashcroft announced he was decertifying the measure, a potentially unprecedented attempt to rescind his previous decision in an attempt to block the measure from the ballot.

The Supreme Court judges said Ashcroft missed his statutory deadline to change his mind.

“Respondent Ashcroft certified the petition as sufficient prior to that deadline, and any action taken to change that decision weeks after the statutory deadline expired is a nullity and of no effect,” the judges wrote.

Amendment 3 — which had been stripped from the Secretary of State’s website on Monday — was again listed under 2024 ballot measures as of 3:30 p.m. Tuesday.

Judge calls Ashcroft’s characterization of abortion amendment ‘unfair’ and ‘misleading’

In order to get a citizen-led Amendment on the ballot, the campaign behind the measure must first collect enough signatures from six of Missouri’s eight congressional districts. When asked for signatures, state law requires that the amendment be attached in full.

The initiative petition circulated by Missourians for Constitutional Freedom did not include any current law that would be repealed, the issue at the crux of the lower court’s ruling.

There is also a section of state law that requires initiative petitions “include all sections of existing law or of the constitution which would be repealed by the measure.”

Attorneys for Missourians for Constitutional Freedom have said the amendment would not repeal the state’s current abortion law or take it off the books. Instead, they said, it would create a new law that would supersede much of the existing one because not every element of the current law would be rendered moot, including laws protecting women who get abortions from prosecution.

And, they added, anything that falls under the scope of the amendment would be left to the judicial system to interpret.

Cole County Circuit Judge Christopher Limbaugh did not agree. On Friday he ruled that the campaign did not meet the sufficiency requirement through a “failure to include any statute or provision that will be repealed, especially when many of these statutes are apparent.”

While Limbaugh recommended the amendment be taken off the ballot, he ultimately left the decision up to a higher court.

Four days later, the Supreme Court ultimately ruled in favor of Missourians for Constitutional Freedom.

“What this decision really says today is that we deserve to be on the ballot,” said Tori Schafer, an attorney with the ACLU of Missouri, which is part of the coalition behind the amendment. ”That people deserve to make this decision for themselves.”

If passed on Nov. 5, the amendment would go into effect 30 days later. At that point, Schafer said there will likely be a series of legal challenges to clarify what the amendment means.

“But it’s very clear that when the amendment goes into effect, our state’s total abortion ban is over,” Schafer said.

The amendment reads in part: “The government shall not deny or infringe upon a person’s fundamental right to reproductive freedom, which is the right to make and carry out decisions about all matters relating to reproductive health care.”

Abortion is illegal in Missouri with limited exceptions for medical emergencies. If the amendment passes by a simple majority, it would legalize abortion up until the point of fetal viability and protect other reproductive rights, including birth control.

Mary Catherine Martin, an attorney with the Thomas More Society who argued the case on behalf of the plaintiffs, called the Supreme Court’s decision a “failure to protect voters.”

“We implore Missourians to research and study the text and effects of Amendment 3 before going to the voting booth,” she said in a statement.

Forck, one of the plaintiffs, was among a handful of anti-abortion activists who remained outside the Supreme Court building once a decision came down.

“We are resolved firmly to let the people of Missouri know exactly how insidious this Amendment 3 is,” she said, later adding: “This is a very slippery slope.”

The Missouri Republican Party called the ruling “devastating.”

“This ruling marks the most dangerous threat to Missouri’s pro-life laws in our state’s history,” the party said in a statement Tuesday. “Make no mistake—this amendment, bankrolled by radical out-of-state interest groups, is a direct assault on Missouri families and the values we hold dear.”

So far, Missourians for Constitutional Freedom has raised more than $15 million for the campaign, including seven-figure donations from national groups whose funders are not listed, including the Fairness Project.

With the general election only eight weeks away, Democratic candidates drew on news of the Supreme Court decision to call on supporters.

“Voters will overturn Missouri’s cruel ban that has zero exceptions for rape and incest,” Crystal Quade, the Democratic nominee for governor, said in a statement. “And they deserve a governor who will protect the will of voters and the rights of every Missourian.”

Lucas Kunce, the Democrat running against incumbent U.S. Sen. Josh Hawley, took an opportunity to call out Hawley’s opposition to Amendment 3.

“The lies and lawfare,” Kunce said, “used by Josh Hawley and his allies to try to block a citizen-led effort to end their total abortion ban have failed.”

This story was updated at 4:50 p.m. to include reaction to the ruling.

Chuck Hatfield, an attorney for Missourians for Constitutional Freedom, argues before the Missouri Supreme Court on Tuesday, Sept. 10, 2024 in Jefferson City as the court hears a case questioning whether an amendment to overturn the state's abortion ban should remain on the November ballot (Pool photo by Robert Cohen/St. Louis Post-Dispatch).

The Missouri Supreme Court heard arguments Tuesday morning over whether to allow an abortion-rights amendment to remain on the Nov. 5 ballot. 

The court will decide whether the campaign behind Amendment 3, which would legalize abortion up until the point of fetal viability and protect other reproductive rights, failed to comply with state law when drafting its initiative petition, the text circulated among registered voters. 

They are expected to rule quickly, since the deadline to remove a question from the ballot is 5 p.m. 

A group of anti-abortion lawmakers and activists filed a lawsuit late last month asking the court to take the measure off the ballot, saying the initiative petition failed to list what specific existing laws would be repealed if the amendment passed. 

Missouri law requires that initiative petitions “include all sections of existing law or of the constitution which would be repealed by the measure.” 

Hours after a bench trial in circuit court on Friday, Cole County Circuit Judge Christopher Limbaugh ruled in favor of the plaintiffs, recommending that the measure be taken off the ballot because the citizen-led ballot measure failed to meet the sufficiency requirement through a “failure to include any statute or provision that will be repealed, especially when many of these statutes are apparent.” But he left the ultimate authority up to a higher court.

In their briefing to the Supreme Court, the attorneys representing the anti-abortion group wrote that no comparable case has been brought before the court in the past. 

“That is because proposed Amendment 3 is novel in its attempt to attach unlimited other subjects to a single, enormous issue that is so controversial that it eclipses all others in the minds of voters, the media and even the secretary of state,” they wrote. 

Chuck Hatfield, an attorney representing Missourians for Constitutional Freedom, the campaign behind the amendment, argued to the Supreme Court Tuesday that the opposition’s briefs were “light on legal arguments but weighty with political argument.”

He chalked the lawsuit — filed by state Sen. Mary Elizabeth Coleman, state Rep. Hannah Kelly, anti-abortion activist Kathy Forck and shelter operator Marguerite Forrest — up to politics. 

“The fact that [abortion] is controversial does not mean that the courts and state officials should cast aside the fundamental right to have that vote,” he said. 

He maintained that because the amendment would not literally repeal any part of the law on its own, the campaign did not err. He added that constitutional amendments never repeal state statutes from the books. Instead, courts can render other statues invalid as a result of further legal action. 

Mary Catherine Martin, an attorney with the Thomas More Society arguing the case Tuesday on behalf of the plaintiffs, reiterated her contention that the initiative petition illegally included more than one subject, pointing to language protecting “a person’s fundamental right to reproductive freedom” and saying such a phrase encompasses “infinite subjects.” 

Attorneys for Missourians for Constitutional Freedom said the single subject is “reproductive freedom.” 

While Limbaugh did not rule on this single subject claim, the Supreme Court has the opportunity to.

After the hearing, both sides agreed on one point: the case is novel. 

Martin called the amendment novel in all that it encompasses.

Tori Schafer, an attorney with the ACLU of Missouri, which is part of the coalition behind the amendment, said the same of the plaintiffs’ procedural arguments.

Schafer said while an amendment hasn’t been ordered off the Missouri ballot in several decades, Limbaugh’s ruling “threatens to grind our system of constitutional initiative petition to a halt at the last minute, leaving in its wake the disenfranchisement of hundreds of thousands of voters …”

Martin said they are not trying to “undermine” voters, but rather “protect” them.

“We’ve worked for 50 years for the right to vote on abortion and I would desperately like, along with all Missouri voters, the opportunity to actually do so,” she said. “And not to have to vote on all of these issues at the same time.”

Amendment 3 would establish the constitutional right to an abortion up until fetal viability and grant constitutional protections to other reproductive health care, including in-vitro fertilization and birth control. It would also protect those who assist in an abortion from prosecution. 

Abortion is illegal in Missouri, with limited exceptions for medical emergencies.

Since the Supreme Court decision in June 2022 through March 2024, there were 64 abortions performed in Missouri under the state’s emergency exemption, according to data from the Missouri Department of Health and Senior Services. 

Meanwhile, thousands of Missourians have crossed state lines for the procedure. Last year, about 2,860 Missourians traveled to Kansas and 8,710 traveled to Illinois for abortions, according to the Guttmacher Institute, a reproductive rights research group that closely tracks abortion data.

Ashcroft decertifies measure ahead of ruling

On the eve of the Supreme Court hearing, Missouri Secretary of State Jay Ashcroft decertified the ballot measure, a potentially unprecedented attempt to rescind his previous decision in an attempt to block the measure from the ballot.

As of Tuesday morning, Amendment 3 remained absent from the secretary of state’s website listing measures to appear on the November ballot.

Ashcroft said he’d mistakenly certified Amendment 3. 

Attorneys representing Ashcroft in Cole County Court on Friday defended his decision. But on Monday, they said he’d realized his error

“This court should simply dismiss this appeal because the appeal has now become moot,” an attorney for Ashcroft told the Supreme Court on Tuesday, adding that Ashcroft believes he has the authority to decertify any measure up until eight weeks before the election.

Judge calls Ashcroft’s characterization of abortion amendment ‘unfair’ and ‘misleading’

Attorneys for the Missourians for Constitutional Freedom in a filing Monday evening asked that Ashcroft be held in contempt of court, adding that his decision went against the court’s stay order filed Monday morning that kept the amendment on the ballot until the highest court’s decision was made.

Hatfield told the judges Tuesday that his team filed a motion asking the court to stay the lower court’s order and keep the amendment on the ballot until they made a decision because “the secretary of state is going to be up to shenanigans and we need a stay” to prevent a “crisis in the system.”  

He recognized the contempt request was “highly unusual” and put the court in a “predicament.”

“It’s open contempt for your authority, It’s open contempt for the rule of law,” Hatfield said of Ashcroft. “It’s open contempt for the proper administration of justice to tell the public that he’s going to take it off the ballot even though we’re here this morning having this discussion.”

Missouri Secretary of State Jay Ashcroft joined the Midwest March for Life on May 1 at the Missouri State Capitol. “I think regardless of what the legislature does, the people of this state – with hard work – can protect all life in this state," Ashcroft said (Anna Spoerre/Missouri Independent).

Missouri Secretary of State Jay Ashcroft decertified a ballot measure that would legalize abortion, a move aimed at blocking it from appearing on the November ballot, according to a brief filed Monday with the state Supreme Court.

Last month, Ashcroft announced the reproductive-rights proposal would appear on the ballot as Amendment 3. But a Cole County judge on Friday ruled the amendment violated state law and shouldn’t have been certified. 

That ruling is now before the Missouri Supreme Court, with a hearing scheduled Tuesday morning and a ruling expected quickly thereafter. The deadline to remove a question from the ballot is also Tuesday. 

But before the Supreme Court had the chance to weigh in, Ashcroft said he had changed his mind. 

“On further review in light of the circuit court’s judgment, the Secretary believes the amendment is deficient,” the secretary of state argues in a filing with the court. 

As of Monday afternoon, Amendment 3 was no longer listed on the secretary of state’s website as appearing on the November ballot.

“The amendment proponents cannot evade constitutional requirements that advocates of other amendments must and have satisfied simply because the proposed amendment concerns a highly charged moral topic,” the brief read. “This court should enforce the circuit court’s judgment.”

Attorneys for the campaign in a filing Monday evening asked that Ashcroft be held in contempt of court, adding that his decision went against the court’s stay order filed Monday morning that kept the amendment on the ballot until the highest court’s decision was made.

“Secretary Ashcroft’s letter directly tends to interrupt this court’s proceeding and impair respect for this court’s authority,” the filing read.

Rachel Sweet, campaign manager for the campaign behind Amendment 3 — Missourians for Constitutional Freedom — said in a statement Monday that the Supreme Court has jurisdiction at this point, not Ashcroft.

Sweet added the campaign is “confident the court will order the secretary of state to keep Amendment 3 on the ballot.”

Cole County Circuit Judge Christopher Limbaugh ruled last week that the measure should be taken off the ballot, but deferred to a higher court for a final ruling. Missourians for Constitutional Freedom quickly appealed.

Missouri law requires that initiative petitions “include all sections of existing law or of the constitution which would be repealed by the measure.” 

During a circuit court hearing Friday, an attorney representing Ashcroft maintained the office believed that the measure met the minimum requirements to be certified. 

Judge calls Ashcroft’s characterization of abortion amendment ‘unfair’ and ‘misleading’

The anti-abortion plaintiffs who challenged the legality of the amendment have argued that because the campaign behind the ballot measure didn’t list the exact statutes that would be repealed on the initiative petition, the measure is invalid. Attorneys representing Missourians for Constitutional Freedom continue to argue that the measure, if passed, would not truly repeal any part of Missouri’s constitution, but rather supersede most of the current ban on the books. 

Missourians for Constitutional Freedom turned in signatures of more than 380,000 Missourians across the state who supported the issue landing on the ballot. If Amendment 3 is ultimately on the Nov. 5 ballot and wins by a simple majority, Missouri could be the first state to overturn an abortion ban.

Amendment 3 would establish the constitutional right to an abortion up until fetal viability and grant constitutional protections to other reproductive health care, including birth control. It would also protect those who assist in an abortion from prosecution. 

Nearly every abortion, with limited exceptions for the life and health of the mother, has remained illegal in Missouri since June 2022, when the U.S. Supreme Court overturned the constitutional right to the procedure. Missouri’s ban does not include exceptions for victims of rape or incest.

The plaintiffs — state Sen. Mary Elizabeth Coleman, state Rep. Hannah Kelly, anti-abortion activist Kathy Forck and shelter operator Marguerite Forrest — said in a statement Friday evening that the amendment’s scope is about more than just abortion and could be interpreted to also include gender-affirming care and human cloning.

This story was updated at 5:55 p.m. to include a filing from attorneys for the Amendment 3 campaign asking that Ashcroft be held in contempt of court.

Supporters of a proposed ballot measure to legalize abortion up until the point of fetal viability gathered at a rally hosted by Missourians for Constitutional Freedom on Feb. 6 in Kansas City (Anna Spoerre/Missouri Independent).

The Missouri Supreme Court will decide whether abortion-rights will end up on the Nov. 5 ballot after a Cole County judge ruled the proposed amendment violated state law. 

The case bypassed the court of appeals over the weekend and headed straight to the state’s highest court, which scheduled oral arguments for 8:30 a.m. Tuesday — the same day ballots are supposed to be printed for those voting absentee. 

Sunday afternoon, attorneys representing the campaign behind the amendment, which would appear on the ballot as Amendment 3, filed an emergency motion asking the court to allow it to proceed to the ballot while the case plays out. Doing so, they argued, would “preserve the status quo and prevent irreparable harm to intervenors-appellants, election officials throughout the state and Missouri voters themselves.”  

Amendment 3 would establish the constitutional right to an abortion up until fetal viability and grant constitutional protections to other reproductive health care, including in-vitro fertilization and birth control. It would also protect those who assist in an abortion from prosecution. 

Abortion is illegal in Missouri, with limited exceptions for the life and health of the mother.

2 years after Missouri banned abortion, navigating access still involves fear, confusion

In late August, a group of anti-abortion lawmakers and activists sued Missouri Secretary of State Jay Ashcroft, accusing him of wrongly certifying the citizen-led ballot initiative for the Nov. 5 ballot nine days earlier. 

Late Friday evening, Cole County Circuit Judge Christopher Limbaugh ruled in favor of the plaintiffs, saying the text of the initiative petition failed to list what existing laws would be repealed if it passed, as he said is required by state law. 

He suggested the amendment be withheld from the ballot, but also left the door open for an appeal to a higher court, saying he recognized  “the gravity of the unique issues involved in this case, and the lack of direct precedent on point.” 

Limbaugh was appointed to the newly-created judicial position in the 19th circuit on Aug. 2 by Missouri Gov. Mike Parson, for whom he previously served as general counsel. 

He was previously a potential candidate to replace Eric Schmitt as Missouri Attorney General after he was elected to the U.S. Senate. His father was a federal court judge and his cousin was the late Rush Limbaugh, a conservative radio host who was awarded the Presidential Medal of Freedom by former President Donald Trump.  

Missourians for Constitutional Freedom, the campaign behind the amendment, quickly appealed his decision.

“Judges come from their own experience and background, and they’re not perfect,” Emily Wales, president and CEO of Planned Parenthood Great Plains Votes, a member of the Missourians for Constitutional Freedom coalition, said Sunday, later adding: “What we’re asking is that the Supreme Court hold us to the same standard everyone else has had.”

Missouri law requires that initiative petitions “include all sections of existing law or of the constitution which would be repealed by the measure.” 

Loretta Haggard, an attorney representing the campaign said during a hearingFriday that the amendment would not literally repeal the state’s current abortion law and take it off the books, but rather would create a new law that would supersede much of the existing one. 

She said this is because not every element of the current law would be rendered moot: the two texts overlap in that both protect women who get abortions from prosecution and both restrict abortion after fetal viability, generally seen as the point at which a fetus can outside the womb, generally around 24 weeks pregnancy. 

Anything else that falls under the scope of the amendment would be left to the judicial system to interpret, Haggard said. 

During the trial, Mary Catherine Martin, an attorney with the Thomas More Society representing the plaintiffs, also argued the initiative petition illegally included more than one subject, pointing to language protecting “a person’s fundamental right to reproductive freedom” and saying such a phrase encompasses “infinite subjects.”

Haggard contended that the single subject was clear: “reproductive freedom.”

While Limbaugh ruled the initiative petition did not meet the sufficiency requirement through a “failure to include any statute or provision that will be repealed, especially when many of these statutes are apparent,” he did not address the single subject claims in his decision. 

The plaintiffs — state Sen. Mary Elizabeth Coleman, state Rep. Hannah Kelly, anti-abortion activist Kathy Forck and shelter operator Marguerite Forrest — said in a statement Friday evening that the amendment’s scope is about more than just abortion and could be interpreted to also include gender-affirming care and human cloning. Neither are mentioned by name in the amendment, nor is in-vitro fertilization.

“There is no way to know if the proponents of this radical amendment would have gathered enough signatures to place this on the ballot if the truth about the staggering scope of laws Amendment 3 invalidates had been disclosed,” they said in a statement. 

Wales said the campaign behind Amendment 3 remains undeterred despite the ruling. 

“We are right on the law. The history of how initiative petitions have worked in this state has meant that they’re able to vote on their rights,” Wales said. “The constitution creates a process for citizens to engage in democracy, not one that’s intended to trip them up or hinder them from participating in democracy. We think the court is going to see that.”  

In May, the campaign turned in signatures from more than 380,000 Missourians across the state who supported the issue landing on the ballot. If Amendment 3 is ultimately voted on in November and wins by a simple majority, Missouri could be the first state to overturn an abortion ban by citizen-vote.

“These ballot initiatives just go through shenanigans, often at the eleventh hour, and what it does again every time is fire people up,” Wales said. “We expect to win, and we’re going to take all the energy and use it to galvanize folks to win in November.”

Mary Catherine Martin, an attorney with the Thomas Moore Society, represented a group of Missouri anti-abortion lawmakers and activists Friday, Sept. 6, 2024, during a trial at the Cole County Courthouse (Anna Spoerre/Missouri Independent).

A Missouri judge ruled Friday evening that a reproductive-rights amendment did not comply with state initiative petition requirements, leaving the door open to potentially withhold it from the November ballot. 

Cole County Circuit Judge Christopher Limbaugh ruled that the coalition behind the citizen-led ballot measure failed to meet the sufficiency requirement through a “failure to include any statute or provision that will be repealed, especially when many of these statutes are apparent.”

A spokesperson for Missourians for Constitutional Freedom, the campaign behind the reproductive-rights amendment, said they plan to appeal. 

Limbaugh also wrote that while he found a “blatant violation” of state law, he “recognizes the gravity of the unique issues involved in this case, and the lack of direct precedent on point.” 

As a result, he won’t issue an injunction preventing the amendment from being printed on the ballot until Tuesday to allow time for “further guidance or rulings” from the appeals court. 

The constitutional deadline for ballots to be printed is Tuesday. 

Amendment 3 would establish the constitutional right to an abortion up until fetal viability and grant constitutional protections to other reproductive health care, including in-vitro fertilization and birth control. It would also protect those who assist in an abortion from prosecution. 

“The court’s decision to block Amendment 3 from appearing on the ballot is a profound injustice to the initiative petition process,” Rachel Sweet, campaign manager with Missourians for Constitutional Freedom, said in a statement. “And undermines the rights of the 380,000 Missourians who signed our petition demanding a voice on this critical issue.

The lawsuit was filed two weeks ago by a group of anti-abortion lawmakers and activists against Missouri Secretary of State Jay Ashcroft, who certified the citizen-led ballot initiative for the Nov. 5 ballot  nine days earlier. The group is arguing that the initiative should never have been allowed on the ballot.

The plaintiffs — state Sen. Mary Elizabeth Coleman, state Rep. Hannah Kelly, anti-abortion activist Kathy Forck and shelter operator Marguerite Forrest — said in a statement Friday evening that the amendment’s scope is “staggering.” 

“Missourians have a constitutional right to know what laws their votes would overturn before deciding to sign initiative petitions,” they said. “Amendment 3 isn’t just about abortion.”

The plaintiffs were represented in court by Mary Catherine Martin, an attorney with the Thomas More Society who argued during a brief bench trial Friday morning that the campaign behind the amendment fell short of the law by failing to list the specific laws or constitutional provisions which would be repealed if the amendment is approved by voters. 

Missouri law requires that initiative petitions “include all sections of existing law or of the constitution which would be repealed by the measure.” 

“No one disputes,” she said, “one of its primary purposes and effects is to repeal Missouri’s ban on abortion.” 

Speculation isn’t necessary to come to this conclusion, Martin said, pointing to the ballot summary which reads, in part, that a yes vote would “remove Missouri’s ban on abortion.”

Loretta Haggard, an attorney representing the campaign supporting the amendment, said that while the amendment would supersede existing law, it would not erase it from the current constitutional text, and therefore would not truly repeal the current statute. 

She told the judge in court that this is because the two texts do have some overlapping similarities: both protect women who get abortions from prosecution and both restrict abortion after the point of fetal viability. 

Fetal viability is an undefined period of time generally seen as the point in which the fetus could survive outside the womb on its own, generally around 24 weeks, according to the American College of Obstetricians and Gynecologists.  

When it comes to everything else, Haggard said, the amendment would leave the current law to be interpreted through the lens of the new law, meaning any restrictions implemented by the government on abortion prior to fetal viability will have to withstand strict scrutiny in court to remain. She ventured that most of Missouir’s current restrictions would not survive for this reason.

Ultimately, Limbaugh sided with the plaintiffs, writing that the page attached to the initiative petition forms “included no disclaimer or any equivalent to a disclaimer.” 

“In fact,” he concluded. “The full and correct text failed to identify any ‘sections of existing law or of the constitution which would be repealed by the measure.’”

Tori Schafer, an attorney with the ACLU of Missouri, speaks to media following a trial over Amendment 3 on Friday, Sept. 6, 2024, outside the Cole County Courthouse (Anna Spoerre/Missouri Independent).

A lawsuit attempting to knock a reproductive-rights amendment off the November ballot could hinge on whether it would immediately repeal Missouri’s current near-total ban on abortion, an issue disputed during a two-hour-long hearing Friday.

Cole County Circuit Judge Christopher Limbaugh said at the completion of Friday’s hearing that he intends to rule quickly because the constitutional deadline for ballots to be printed is Tuesday. 

Two weeks ago, a handful of anti-abortion lawmakers and activists filed a lawsuit against Missouri Secretary of State Jay Ashcroft, who certified the citizen-led ballot initiative for the Nov. 5 ballot  nine days earlier. The group is arguing that the initiative should never have been allowed on the ballot, and they are asking the judge to keep it from being voted on this fall. 

The plaintiffs — state Sen. Mary Elizabeth Coleman, state Rep. Hannah Kelly, anti-abortion activist Kathy Forck and shelter operator Marguerite Forrest —are being represented by Mary Catherine Martin, an attorney with the Thomas More Society.

All but Forrest were part of a lawsuit last year challenging the estimated cost of a proposed constitutional amendment ending the abortion ban.

Missourians for Constitutional Freedom, the campaign behind the amendment, turned in more than 380,000 signatures from Missouri voters across the state, clearing the threshold to earn a place on the statewide ballot, where it needs a simple majority to pass. 

Amendment 3 would establish the constitutional right to an abortion up until fetal viability and grant constitutional protections to other reproductive health care, including in-vitro fertilization and birth control. It would also protect those who assist in an abortion from prosecution. 

Martin argued Friday that the amendment illegally includes more than one subject, pointing to language protecting “a person’s fundamental right to reproductive freedom” and saying such a phrase encompasses “infinite subjects.”

She contends the amendment could have further-reaching effects that it doesn’t specify, including on Missouri’s current laws prohibiting human cloning, prohibiting the creation of a pre-implanted embryo through in-vitro fertilization solely for the purpose of stem cell research and prohibiting minors from getting gender-affirming health care. 

While none of the above issues are specifically mentioned in the amendment, Martin said she believes they still fall under its scope.

“We believe and think it’s pretty evident that cloning and reproductive technologies are matters related to reproductive health care,” Martin said. 

Loretta Haggard, an attorney representing the campaign supporting the amendment, said trying not only to imagine, but also to list, every law that could be affected by the amendment would be “impossibly burdensome.”  

While Amendment 3 would substantially alter the existing ban, Haggard said what current laws it applies to will need to be determined on a case-by-case basis.

“At most there is speculation about how and to what extent Amendment 3 will affect the existing constitutional ban on human cloning.” Haggard said. “Those disputes need to be decided by courts in future cases in light of specific facts with controversies, not by this court.” 

Haggard said the amendment’s single subject and central purpose is clear: “reproductive freedom.”

Martin also claimed the campaign behind the amendment fell short of the law by failing to list the specific laws or constitutional provisions which would be repealed if the amendment is approved by voters. 

Missouri law requires that initiative petitions “include all sections of existing law or of the constitution which would be repealed by the measure.” 

“No one disputes,” she said, “one of its primary purposes and effects is to repeal Missouri’s ban on abortion.” 

Speculation isn’t necessary to come to this conclusion, Martin said, pointing to the ballot summary which reads, in part, that a yes vote would “remove Missouri’s ban on abortion.”

Haggard contends that while the amendment would supersede existing law, it would not erase it from the current constitutional text, and therefore would not truly repeal the current statute. She said this is because the two texts do have some overlapping similarities: both protect women who get abortions from prosecution and both restrict abortion after the point of fetal viability. 

Fetal viability is an undefined period of time generally seen as the point in which the fetus could survive outside the womb on its own, generally around 24 weeks, according to the American College of Obstetricians and Gynecologists.  

When it comes to everything else, Haggard said, the amendment would leave the current law to be interpreted through the lens of the new law, meaning any restrictions implemented by the government on abortion prior to fetal viability will have to withstand strict scrutiny in court to remain. She ventured that most of Missouir’s current restrictions would not survive for this reason.

“The measure writes a road map,” she said, “and it’s up to courts and parties in concrete cases to apply those rules in the future.” 

Following the hearing, Tori Schafer, an attorney with the ACLU of Missouri, stood outside the courthouse alongside a few dozen people waving signs in support of the amendment.  

“The most pressing question for the judge right now is ‘does it make legal sense to kick something off the Friday before ballots are to be printed on a Tuesday?’” she asked.” And the answer to that is no.”

Martin said time will tell. 

“Whatever does happen, surely both parties intend to seek whatever review is available by Tuesday and then on into the future,” Martin said outside the courtroom. “This will not be the last day, no matter what happens.” 

This story may be updated.

Cole County Circuit Court Judge Cotton Walker listens to arguments during a Sept. 8, 2022, hearing (pool photo courtesy of Emily Manley/Nexstar Media Group).

A judge could decide as early as Thursday whether Missouri Secretary of State Jay Ashcroft’s “fair ballot language” summary for an abortion-rights amendment is truly fair. 

Missouri voters will be asked on Nov. 5 whether they support Amendment 3, which would establish a constitutional right to an abortion up until fetal viability and protect other reproductive rights, including access to in-vitro fertilization and birth control. Abortion became illegal in Missouri in June 2022, with limited exceptions for the life and health of the mother.

Posted at every polling station around the state, next to sample ballots, is “fair ballot language” that summarizes the questions that voters will be asked to decide on. State law requires that this language, written by the secretary of state, be “true and impartial.”

In a lawsuit filed two weeks ago, organizers behind Amendment 3 claimed that Ashcroft’s summary was “intentionally argumentative” and could create confusion among voters. 

The same day Ashcroft certified the measure for the November ballot, his office also published to its website a “fair ballot language” summary statement for the amendment which reads: 

“A ‘yes’ vote will enshrine the right to abortion at any time of pregnancy in the Missouri Constitution. Additionally, it will prohibit any regulation of abortion, including regulations designed to protect women undergoing abortions and prohibit any civil or criminal recourse against anyone who performs an abortion and hurts or kills the pregnant women.” 

Missouri voters will decide whether to legalize abortion in November 

The abortion rights campaign is asking the court to issue new “fair ballot language” and order that Ashcroft remove his current language from his government website.

A brief bench trial Wednesday afternoon in Cole County Circuit Court focused in particular on the last sentence of Ashcroft’s summary, and how a court could interpret subsection 5 of the amendment, which reads: “No person shall be penalized, prosecuted, or otherwise subjected to adverse action based on their actual, potential, perceived, or alleged pregnancy outcomes, including but not limited to miscarriage, stillbirth, or abortion. Nor shall any person assisting a person in exercising their right to reproductive freedom with that person’s consent be penalized, prosecuted, or otherwise subjected to adverse action for doing so.”

Andrew Crane, representing Ashcroft on behalf of the Missouri Attorney General’s Office, argued Wednesday that this subsection would result in “effectively neutering the government’s ability to enforce any effective regulations” on abortion. 

Tori Schafer, an attorney with the ACLU of Missouri, which is representing the plaintiff, called this claim “politically-charged” and unfounded, as it fails to take into account other language in the amendment protecting patients.

“The amendment will provide greater independence from the government,” she told the court. “But it does not create the boundless, limitless, unregulated right the secretary continues to make it to be.” 

Schafer said Ashcroft in the latest language “resurrects his false claims” that have already been denounced by the Missouri Court of Appeals.

Ashcroft was sued last year by the abortion-rights campaign over the initial ballot summary he drafted, which would have asked Missourians, in part, if they wanted to “allow for dangerous, unregulated, and unrestricted abortions, from conception to live birth.” 

Cole County Circuit Judge Jon Beetem ruled a year ago that Ashcroft’s language was “problematic” and inaccurate. 

An appeals court agreed, ruling that it is “not a probable effect” that the amendment would allow unrestricted abortion in all nine months of pregnancy or that it would toss aside health and safety regulations, “including requirements that physicians perform abortions and that they maintain medical malpractice insurance.”

However, Crane on Wednesday argued that the appeals court ruling didn’t specifically address the immunity provisions of subsection 5.

Ashcroft, who recently lost a bid for the GOP candidate for governor, has been open about his opposition to abortion. 

During the Midwest March for Life outside in May, he told The Independent of the abortion initiative petition: “I just want to make sure that people know what this amendment will actually do. That it’s abortion from conception until the very last second that the last toenail leaves the birth canal.”

Cole County Circuit Judge Cotton Walker, who is overseeing the current case, said he intends to rule on Thursday. 

Walker recently upheld the “fair ballot language” summary written by Ashcroft for a proposed constitutional amendment that would ban ranked-choice voting after two voters sued over the language. The voters called the language imprecise, in part because it doesn’t state that it’s currently illegal for non-citizens to vote in Missouri. 

The Amendment 3 lawsuit was filed by retired physician Dr. Anna Fitz-James, who initially filed the abortion rights initiative petition in spring 2023 on behalf of Missourians for Constitutional Freedom, the campaign behind the amendment. 

The campaign has raised millions of dollars this election cycle, and recent polling by St. Louis University/YouGov showed 52% of Missouri voters supported Amendment 3. The poll surveyed 900 voters across nine days in August.

Meanwhile, a second lawsuit regarding Amendment 3 is also pending in Cole County after a number of anti-abortion activists and lawmakers asked a judge to block the amendment from the Nov. 5 ballot. Their lawsuit claims Amendment 3 violates the state constitution by including more than one subject and fails to specify which laws and constitutional provisions would be repealed if it was approved.

A bench trial in that lawsuit is scheduled for Friday.

Residents assess a fallen tree in their Houston neighborhood after Hurricane Beryl swept through the area on July 8. As climate change has fueled more intense and frequent natural disasters, emergency responders face challenges from burnout to budgets (Brandon Bell/Getty Images)

AUSTIN, Texas — Four days after residents of coastal Houston celebrated the Fourth of July with the traditional parades, backyard barbecues and fireworks, Beryl came calling.

The Category 1 hurricane, weakened from an earlier Category 5, slammed into Texas’ largest city on July 8 — an unusual midsummer arrival. Delivering one of the worst direct hits on Houston in decades, Beryl flooded streets, ripped down trees and left thousands without power, causing multiple heat-related deaths during a period of triple-digit temperatures.

Superlatives like “worst,” “biggest” and “most” increasingly sprinkle news accounts in disaster coverage. Even as residents of Houston deal with Beryl’s lingering impact, farmers and ranchers in the Texas Panhandle are still trying to recover from the largest recorded wildfire in the state’s history, a February inferno that consumed more than a million acres of land, an estimated 138 homes and businesses, and more than 15,000 head of cattle. Three area residents were killed.

Climate change has rewritten the script for disasters, leaving communities vulnerable to weather patterns that don’t abide by schedules or the rules of past behavior. As a result, hundreds of thousands of emergency responders are facing unprecedented challenges —from burnout to post-traumatic stress disorder to tighter budgets — as they battle hurricanes, windstorms, wildfires, floods and other natural disasters that are more frequent and intense than those in the past.

“Everybody’s strapped,” said Russell Strickland, Maryland’s secretary of emergency management, who also serves as president of the National Emergency Management Association, or NEMA, the professional group for state emergency management directors.

Agencies are grappling with “stagnant budgets and staff shortages” at a time when they need more money and people to deal with disasters and confront other demands, Strickland said. In the 1980s, states averaged just over three $1 billion weather disasters a year in cost-adjusted dollars, according to the association. In each of the past three years, the average has been 20. Last year, the nation was hammered by a record 28 of those billion-dollar catastrophes.

In a 2023 white paper, NEMA reported that “the COVID-19 pandemic and the increasing number of back-to-back disasters have resulted in disaster fatigue and burnout.” It also reported that current funding levels for most emergency management agencies are “wholly inadequate to address the types of events that states are experiencing along with expanding mission areas.”

The nation’s disaster response system is a massive multilevel network that includes the Federal Emergency Management Agency, which is charged with dispatching hundreds of millions of dollars in federal grants to battered states and communities, and counterpart state disaster agencies that advise or report to the governor. County and city governments also operate disaster and homeland security units.

Disaster officials throughout the country acknowledged that natural disasters such as wildfires, tornadoes and floods have increased and intensified as a result of climate change. Moreover, disaster agencies are being tasked with nontraditional assignments such as cybersecurity, opioid addiction, homelessness and school safety.

A U.S. Government Accountability Office report published in May of last year said that state demands for FEMA assistance have “increased with more frequent and complex disasters like hurricanes, wildfires and the COVID-19 pandemic” but that “FEMA has had trouble building a workforce to meet these needs.”

Budgets for state emergency management are funded by state legislatures and vary widely. The biggest states allocate a half-billion dollars while the smallest set aside closer to a half-million, according to a NEMA examination of state emergency management budgets.

California’s emergency management unit, attached to the governor’s office with nearly 2,000 employees, had the largest budget as of the 2022 fiscal year, with more than $530 million, according to the NEMA report. California is the nation’s largest state with 39 million people. By contrast, Vermont, which has less than a million people, had a fiscal year 2022 budget of $650,000 to fund 34 emergency management personnel, according to NEMA.

Texas, whose emergency management division teams works with the governor’s office and is based in the Texas A&M University System, had one of the largest budgets, $33.5 million to fund close to 500 employees, as of the 2022 fiscal year.

State emergency management agencies, which also receive money from the federal government, including FEMA, constitute the central nerve center during major disasters, typically working from a strategically located emergency operations center that includes representatives from various other agencies. Real-time information begins pouring in hours before the crisis, resulting in an all-points response that ultimately encompasses legions of state and local police, sheriff’s deputies, EMS, firefighters, relief agencies and a long list of other responders.

Heavier strain on emergency workers

As he took a late-morning break from battling a recent 11-acre brush and grass fire near Smithville, a small town about 50 miles southeast of Austin, 36-year-old state firefighter Billy Leathers reflected on his 18-year career with the Texas A&M Forest Service, which helps local fire departments fight outdoor blazes. A charred grassy hillside stretched behind him.

Leathers is a third-generation firefighter who followed his parents and grandfather into the job.

“That’s the only one that I found that I liked,” he said of being a firefighter, adding that he and his co-workers “wouldn’t do it if we didn’t like helping people.” But he acknowledges that the increasing pace “does kind of start to run you a little bit ragged towards the middle of the season.”

The job increasingly involves more than fighting fires.

In 2020, Tennessee responders confronted a bombing on Christmas Day in downtown Nashville, when a 63-year-old conspiracy theorist apparently intent on suicide parked his recreational vehicle near an AT&T facility and ignited an explosion that took his own life, injured eight others and triggered dayslong communication outages.

Tennessee also has faced a relentless surge of more traditional disasters, said Patrick C. Sheehan, who has directed the Tennessee Emergency Management Agency since 2016. In the 1980s, Tennessee had only three major natural disasters caused by severe storms and flooding. Since January 2014, the state has had 24 major disaster declarations.

“We’re having incredible, record-breaking rainfall,” Sheehan said. “We’re having record-breaking cold. We’re having record-breaking heat. We’re having tornadoes earlier and later.”

Sheehan and other emergency managers point out that climate change’s continually shifting weather patterns now make it almost impossible to precisely predict a so-called season for storms such as hurricanes and tornadoes. As illustrated by Hurricane Beryl, coastal storms are increasingly arriving earlier and in greater strength.

“We expect weaker hurricanes to decrease in frequency and stronger ones to increase in frequency,” said John Nielsen-Gammon, the Texas state climatologist.

More residents, more danger

Texas’ chief disaster responder is Nim Kidd, a former San Antonio firefighter who heads the Texas Division of Emergency Management and who is typically alongside Texas Republican Gov. Greg Abbott during briefings on tornadoes, fires, floods or other weather events.

The division was formerly attached to the Texas Department of Public Safety, the state police force, and was transferred to the Texas A&M System in 2019, putting it under the same umbrella as firefighters in the Texas A&M Forest Service. Kidd is also A&M vice chancellor for disaster and emergency services.

Forest Service Director Al Davis and Deputy Director Wes Moorehead said the wildfire danger in Texas has steadily increased with the state’s surging growth as more and more people migrate to the state, often settling in attractive areas close to trees and brush that become vulnerable to ignition during drought and triple-digit heat.

“They like a little bit of nature around them,” said Moorehead. “They want some trees, some grasses and vegetation. And in Texas that grass, that vegetation, those trees — that is fuel for a wildfire.”

The state’s disaster and firefighting operations came under scrutiny during a state House of Representatives hearing on the catastrophic Panhandle fires, which started Feb. 26 after a downed power line set off the blaze that ultimately advanced 95 miles, reaching into Oklahoma.

Local concerns focused heavily on delays in engaging aircraft into the firefighting effort, since the state doesn’t have its own firefighting fleet and relies on private contractors. The state’s first order for aerial fire-suppression equipment from the federal government wasn’t made until 24 hours after the so-called Smokehouse Creek fire erupted, the investigative committee found.

Kidd, testifying at the hearing, endorsed the creation of a state-owned firefighting fleet, which also was recommended by the five-member panel.

The Panhandle investigation also underscored the importance of volunteer fire departments in augmenting government emergency response agencies. Committee members found that volunteer departments are “grossly underfunded,” further undercutting emergency preparedness.

Many first responders say they tolerate the danger, stress and low pay because they want to serve, said Moorehead, of the Texas forest service.

“When you’ve got people with the drive and the willingness and the service mindset to go out and do right and do good for the citizens of the state,” he said, “you can overcome shortages like you’d never imagine.”

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

Missouri is a particularly smoking-friendly state. Tobacco use is highest in rural areas, which also have higher rates of the lung and heart disease that come with smoking (Cami Koons / The Beacon)

Families flock to McDonald County in southwest Missouri each summer to float down the Elk River, visit the caves where Jesse James took refuge and stay in a rustic cabin.

The county is a vestige of old, wild Missouri charm — and a place where restaurants and bars still ask, “Smoking or non?”

People in McDonald County, like those in other rural places across Missouri and the country, smoke more. The U.S. Centers for Disease Control and Prevention says smoking runs even higher in rural Missouri than in rural America as a whole.

Groups that research and advocate for decreasing tobacco consumption connect that to Missouri’s cigarette taxes, the lowest in the country, and relatively weak rules backing smoke-free public places.

Some rural communities across the state, including McDonald County, are enacting their own smoke-free ordinances and in-restaurant policies to improve health outcomes and fall in rhythm with their urban neighbors.

“We want more people staying here, living here, coming here (for) tourism –– we just want to keep people coming back to McDonald County,” said Kayla Langford, the assistant director at the health department.

Chronic lower respiratory diseases are the third highest cause of death in the state and run more than 20% higher in rural areas, according to data from Missouri Department of Health and Senior Services. The report attributes the deaths, in part, to high smoking rates.

Experts say some policies have strong records in lowering smoking rates.

“One of the exciting things about tobacco prevention is it’s actually a solvable problem,” said Nicole Sinderman, who leads the state’s Tobacco Prevention and Control Program. “There are evidence-based solutions that have been proven to work.”

The Missouri Department of Health and Senior Services, or DHSS, program works on four main platforms: media campaigns, creating smoke-free places, increasing access to cessation services and raising tobacco taxes.

Missouri taxes cigarettes at 17 cents a pack. Advocates for tobacco prevention want to add $1. Top tobacco-reduction organizations predict that would cut the number of people under 18 who smoke by almost 8% and trim the total number who smoke by at least 4%.

The same advocates also want to double the tax on other tobacco products like vapes, chew and dip.

The Missouri tobacco law’s preemption clause bars cities and counties from adding local surcharges.

Voters have rejected five different versions of tobacco tax increases since 2002. The issue is not on the November ballot, though several unsuccessful initiative petitions were circulated this year.

Tobacco sales make up a significant portion of business for convenience stores and grocery stores.

Ronald Leone, executive director of Missouri Petroleum & Convenience Association (MPCA), said Missouri’s low cigarette tax gives businesses a competitive advantage.

“It draws customers from our higher taxed border states who spend their money in Missouri on gasoline, tobacco, and other goods,” Leone said in an email statement.

MPCA sponsored a tobacco tax increase, Proposition A, in 2016 to counter a much higher tax increase proposal, Amendment 3. Ultimately, neither passed.

A U.S. Department of Health and Human Services study found that increasing tobacco prices by 20% would reduce consumption by 10% and reduce the number of young people who start smoking by 8%.

In the past two years, Missouri has significantly increased its allocation to tobacco prevention programs, though it still sits as one of 19 states that spend less than 10% of what the CDC recommends, according to Campaign for Tobacco-Free Kids.

Missouri DHSS runs several of these programs and partners with local health departments to give people the resources and incentives to quit.

Some programs offer counseling and nicotine replacement therapy. Others work with pregnant mothers and give them incentives for quitting, like gift cards for diapers and wipes. Missourians who want to quit can also call 1-800-QUIT-NOW (1-800-784-8669) or text the helpline (“start my quit” to 36072).

Langford and her co-coordinator Tina Hang started a tobacco cessation program at the McDonald County Health Department.

“We’re still adapting our policies to see what would work best for the health department,” Hang said. “But for the most part, it’s going pretty well.”

The program is free to McDonald County residents. When they come into the department, Hang assesses their willingness to quit and the best methods for them. Then she offers them counseling and nicotine lozenges, gum or patches.

The county’s anti-smoking campaign sprang from a Building Communities for Better Health state grant to reduce preventable causes of chronic diseases.

Langford said her county ranks particularly high in physical inactivity and tobacco use, so they focused the grant money on building walking and biking trails and implementing smoke-free air policies.

“Biking and active transportation go hand in hand with tobacco, because most people who are wanting to use these facilities want it to be a clean environment,” Langford said.

The department started the initiative in the county seat, Pineville.

Melissa Ziemianin, Pineville’s city clerk, helped with the ordinance, which passed without pushback. It has been effective in reducing cigarette and vape use and the associated litter in city parks.

“We thought that if we could take out smoking in our parks and in our areas where kids were seeing it, … maybe then it would make that change where kids didn’t think it was OK,” Ziemianin said. “Maybe in the long run, we would see (children) not want to pick up cigarettes.”

Sinderman said smoke-free air policies are the basis of tobacco prevention, and rural communities across the state are taking similar actions.

“It’s not really a coincidence that in a lot of the counties where use is high, there are no smoke-free policies,” Sinderman said. “Smoking remains a social norm in rural communities, and I think part of it is the lack of smoke-free policies.”

Missouri laws currently prohibit smoking in child care facilities and require restrictions in schools, government buildings, health care facilities and restaurants, according to the American Lung Association.

Bars, private workplaces, bowling alleys and casinos have exemptions. Sinderman said that exposes more people to secondhand smoke.

All casino workers in Missouri live without smoke-free protection laws, according to a Bridging the Gap report by American Nonsmokers’ Rights Foundation. The same report finds that over 70% of Missourians are not protected from exposure to secondhand smoke.

Sinderman said tobacco prevention isn’t just a presentation at school with a set of blackened lungs –– it’s about making community changes.

“It’s really changing the environment to make the healthy choice, the easy choice,” she said. “People don’t become addicted in the first place. … Those who are already addicted, you’re giving them a healthy environment where they can quit.”

McDonald County got another round of the same grant to make changes in Noel, a town of 2,100 people nestled between huge bluffs and the banks of the Elk River.

Noel is considering an ordinance that would bar smoking in city-owned parks. Meanwhile, Langford and Hang have worked with local businesses to establish their own no-smoking policies.

Many of the bars and restaurants in town don’t allow smoking, but Langford wants them to establish policies to point at if a customer were to challenge that request.

The bars that do allow smoking inside continue to do so for fear of alienating their clientele, especially during the colder months — when people are more annoyed at having to step outside for a smoke.

Local bar owner Robert Miller got involved with the process and has become an advocate for the active transportation and smoke-free efforts.

He bought his historic bar, Shadow Lake, in 2021 with his wife and added a VIP room with a no-smoking policy this year.

So far, he hasn’t had any pushback. He recently booked the VIP space to an older crowd for a high school reunion.

“That definitely wouldn’t have happened with that age group and crowd if we hadn’t had that space,” Miller said. “So even nonsmokers that typically won’t go to any establishment that has smoking don’t mind coming here.”

His bar thrives on river tourism, like most of the town. He sees the healthy-community initiatives as a way to expand the area and full-time population.

“The sidewalks and the tobacco policies, they really all work together,” Miller said. “If we can start offering some of these things, even just sidewalks, to make the city look nicer, it’ll start attracting those people.”

Beyond the potential economic benefit, Miller wants to see a healthier community.

“I stopped smoking before I bought the bar, and then being around it all the time made it so hard not to smoke,” Miller said. “Taking these steps has helped me take steps back too, in the right direction.”

This article first appeared on Beacon: Missouri and is republished here under a Creative Commons license.

A sign marks the entrance to the a drive-through COVID-19 vaccine clinic at the Shannon County Health Center on July 8, 2021 (Tessa Weinberg/Missouri Independent).

A summer COVID wave fueled by a highly contagious variant, increased travel and hot days that crowded people indoors may be starting to ebb in the Kansas City area.

Health officials said they hope that surge prompts far more people to sign up for the new COVID vaccine, which could reach area pharmacies next week. The new shot was approved last week and is recommended annually for people 6 months and older.

“Please take advantage of it,” said  Dr. William Schaffner, a professor of infectious diseases at Vanderbilt University Medical Center. “Roll up both sleeves. Get your flu shot and your COVID shot.”

Last year, the U.S. Centers for Disease Control and Prevention reported that fewer than a quarter of adults actually got the new COVID vaccine.

Getting the updated vaccine, doctors agree, is the best way to prevent serious illness and reduce the risk of developing long COVID, a lingering and often debilitating condition that can leave a person with symptoms for months or years.

But since the federal government lifted its public health emergency in May 2023 and stopped providing the vaccine for free, public health officials have worried about how some people would afford it. Cash price for a shot can top $100.

People covered by Medicare, Medicaid and most private insurance can still get the shot for free or for a small fee. And a $1 billion federal program made free shots available to people without insurance last year. But funding for that program was expected to run out at the end of August.

Some area health departments, including the Wyandotte County Public Health Department, had said they wouldn’t have any free shots for uninsured adults this year. And Vibrant Health, a Wyandotte County health clinic, said it’s still unsure how many free shots will be available to its uninsured patients this fall.

But as federal funding was scheduled to dry up, the government announced it had found money to help cover at least some of the gap.

Kansas expects to get around $780,000 of the newly found federal aid, enough to cover about 9,380 COVID doses. The state, which hasn’t expanded Medicaid, has nearly 250,000 residents who lack health coverage.

Jill Bronaugh, spokesperson for the Kansas Department of Health and Environment, said the shots would be “equitably distributed” across the state to local health departments, community health centers, rural health clinics and other vaccination locations.

Missouri got word last week that it would get just over $1.1 million of the federal funds. That means the state can buy around 12,000 COVID shots. The state, which has expanded Medicaid, still has more than 500,000 uninsured residents, according to 2022 data.

Lynelle Paro, chief of Missouri’s Bureau of Immunization in the Department of Health and Senior Services, said the shots will be made available to public health departments and to some federally qualified health clinics, including Samuel U. Rodgers Health Center, KC CARE Health Center and Swope Health.

Dr. Mark Steele, University Health’s chief clinical officer, said people at lower risk of getting really sick from COVID could consider waiting to get the updated shot until late September or early October. That could extend protection into the holiday season.

But doctors warn about putting it off any longer. The virus is sure to surge again once the weather turns cold, a new variant likely takes hold and people go back inside.

“If you’re an individual at high risk and it’s been two months or more since your last COVID update, err on the side of (getting the new shot) sooner rather than later,” Steele said.

Here’s what else you should know about the latest shot and what steps to take if you get infected.

Where can I get the new COVID vaccine and how much will it cost?

Many pharmacies offer the vaccine on a walk-in basis. Retail chains like Walgreens and CVS let you sign up through their websites. People covered by Medicare, Medicaid and many private insurance plans still can get the COVID shot for free, but you may have to pay an administration fee. Some area health departments charge $20 to give you the shot, even if you don’t have insurance. Many federally qualified health centers, such as KC CARE, provide the shot for free to uninsured and underinsured patients. Uninsured and underinsured minors get the shot for free through a federal program known as Vaccines for Children.

What variant is the latest vaccine targeting?

The newly approved mRNA vaccines, from Moderna and Pfizer, target the KP.2 strain of the virus. KP.2 is one of the FLiRT variants, the highly contagious versions of COVID that fueled this summer’s surge.

If I had COVID recently, how long should I wait to get the new COVID vaccine?

Doctors said you can wait up to three months after an infection to get the new vaccine. That’s because you will develop immunity from having the virus.

How long will the vaccine protect me?

Steele said you can expect the shot to keep you from getting sick for about three months. The vaccine will protect you from getting seriously ill for at least six months. Older adults and patients with underlying health conditions may be advised to get a second shot midway through the year.

If I get sick, when should I test?

Test when you have symptoms, said Dr. Sarah Boyd, an infectious disease doctor at St. Luke’s Health System. And don’t assume you’re COVID-free if one home antigen test shows a negative result. When a cough, sore throat or other symptoms persist, you should test a second time 48 hours later to rule out COVID.

If I am exposed, when should I test?

If you know you’ve been exposed and you don’t have symptoms, you should test five days after exposure. Unless symptoms develop, you don’t need to repeat the test, Boyd said.

Where can I get COVID tests?

Beginning in late September, you will be able to order four free tests from the federal government. Tests are available to buy at most drug stores or online, but that can cost $6 a test or more. No-cost testing is still available at some pharmacies for people without insurance who have been exposed to COVID or have symptoms.

If the test is positive, do I need to stay home?

The CDC recommends that if you test positive, you should avoid contact with others. Once your symptoms are improving and you have been fever-free for 24 hours, you can go back to school or work — as long as you’re not returning to a health care setting. But when you go back into the world, you should take precautions like wearing a mask for five additional days.

Should I consider taking Paxlovid if I test positive?

It’s a good idea to check in with your doctor if you test positive, Boyd said. They may recommend that you take Paxlovid, an antiviral medication that can prevent serious illness. Testing and determining that you have COVID is especially important for people at higher risk because Paxlovid must be started within five days of getting sick.

How can I reduce my risks of getting long COVID?

The best strategy to avoid long COVID is to avoid being infected in the first place, experts said. Wear a mask in crowded places, practice good hand hygiene and avoid touching your eyes, nose and mouth when in public. Most importantly, stay up to date on the vaccine. Like the flu shot, updated COVID vaccines are tweaked to more closely match and repel the virus variants that are circulating.

This article first appeared on Beacon: Kansas City and is republished here under a Creative Commons license.

Mariners Hospital in the Florida Keys was evacuated to prepare for Hurricane Irma in September 2017. Experts say cities and counties are assuming a greater role in the state’s response to climate change’s cascading effects on public health (Marc Serota/Getty Images).

ORLANDO, Fla. — Florida is the hottest state in the contiguous United States, and its residents suffer the most heat-related illness. Older people are most susceptible to the heat, and nearly 4.7 million Floridians — 1 in 5 residents — are older than 65.

The peninsula has 8,436 miles of coastline, and three-quarters of state residents live in coastal counties, imperiled by rising sea levels, extreme rainfall and more intense hurricanes.

Climate change is making Florida hotter and increasing the risk of flooding and severe storms. Increasingly, the state should expect “adverse public health outcomes, such as heat-related illness and mortality, especially among more vulnerable populations,” according to the state climatologist’s office at Florida State University.

But Republican Gov. Ron DeSantis has opposed many efforts to address the causes and public health effects of climate change. As a result, Florida cities, counties and nonprofits have had to assume a greater role in dealing with higher temperatures — without sufficient money and resources to do so, many argue.

Perhaps more than any other state, Florida illustrates how the politicization of climate change has thwarted efforts to deal with it.

Florida, unlike a growing number of other states, does not a have a statewide plan designed specifically to help residents cope with extreme heat and other effects of climate change. Dr. Cheryl Holder, co-chair of Miami-Dade County’s Climate and Heat Health Task Force, said that in the absence of state leadership, Florida cities and counties have done what they can. In 2021, for example, Miami-Dade County named its first-ever chief heat officer, and last month Tampa released a “heat resilience playbook” that includes steps such as enhancing and protecting the city’s tree canopy.

But Holder said a statewide effort — akin to public health campaigns to curb smoking — would have a much greater impact.

“Systematic change is better, but we’re left with a piecemeal approach,” Holder told Stateline.

In Florida and around the country, state public health leadership is essential, said University of Washington professor Kristie Ebi, an epidemiologist and an expert on the health risks of climate change.

“The local health departments follow the lead of the state health department, and it’s difficult to contravene,” Ebi said. “It’s difficult when the state health department says, ‘This is the approach, this is the perspective, these are the parameters,’ for the local health department to do anything differently.”

DeSantis’ office, the Florida Department of Health and the Florida Department of Environmental Protection did not respond to Stateline requests for comment before publication.

A bipartisan concern in the past

As recently as 2008, climate change was a bipartisan concern in Florida. But DeSantis, who unsuccessfully sought the GOP presidential nomination this year, embodies his party’s current dismissive attitude toward climate change — a stance shared by his predecessor in the Florida governor’s office, current U.S. Sen. Rick Scott.

In May, for example, DeSantis signed legislation erasing references to climate change from the state’s energy policy and releasing state agencies from the obligation to consider climate change when executing it. “We’re restoring sanity in our approach to energy and rejecting the agenda of the radical green zealots,” DeSantis wrote on X.

In April, DeSantis signed a law barring Florida cities and counties from passing their own heat protections, such as mandated water breaks, for outdoor workers. As a result, Miami-Dade County had to withdraw its pending rule that would have required water breaks for outdoor workers and training on heat-related illness for employers.

Texas Republican Gov. Greg Abbott last year signed a similar law preempting cities from passing heat-break ordinances.

Meanwhile, many other states are moving in the opposite direction.

States such as Arizona, California, Connecticut, New York, North Carolina and Wisconsin have used federal money from the Centers for Disease Control and Prevention to craft statewide plans to address the effects of climate change on public health. All have Democratic governors.

In April, Democratic-led New Jersey released a draft Extreme Heat Resilience Action Plan that includes providing public cooling centers, planting more trees, and adopting workplace safety rules, among many other steps.

California launched and New Jersey plans to start statewide public information campaigns to raise awareness of the risks of extreme heat, especially among vulnerable populations such as older and homeless people.

Florida State University also received a CDC grant, but the team is focused on working with local health departments, said project lead Chris Uejio, a medical geographer and associate professor at FSU.

“We’re always ready and willing partners if and when the state decides that they’d like some more information along these lines,” Uejio said.

‘Falling behind the pack’

Despite downplaying climate change concerns, DeSantis in 2021 approved $640 million in new state spending to help communities deal with sea level rise, intensified storms and flooding. And in 2019, he appointed the state’s first chief resilience officer.

But DeSantis’ interest in such efforts waned as his presidential campaign ramped up. Florida was one of five states (Iowa, Kentucky, South Dakota and Wyoming were the others) that declined to apply for federal Climate Pollution Reduction Grants under President Joe Biden’s Inflation Reduction Act. The federal government allowed large metro areas to apply for their own climate planning grants. Five Florida areas applied for their own and received dollars for planning, but no grants for implementation.

A year ago, DeSantis rejected nearly $350 million in federal energy efficiency incentives and consumer rebates under the Inflation Reduction Act. But this year, after dropping out of the primary race, DeSantis accepted the money.

Susan Glickman, vice president of policy and partnerships at the CLEO Institute, a Florida-based nonprofit focused on climate education and advocacy, praised the state for addressing sea level rise and for assessing the vulnerabilities of coastal communities. But Glickman said Florida must address the root causes and cascading effects of climate change.

“We must adapt to the warming climate, but the decisions we make right now, not addressing the root cause of the problem, is really unacceptable,” Glickman said. “You cannot adapt your way out of climate change.”

Kim Ross, executive director of ReThink Energy Florida, a Tallahassee-based nonprofit that advocates for clean energy, said the DeSantis administration has been a roadblock.

“This could be a state that’s really focused in on the inventions that need to happen,” Ross said. “Instead, we’re just kind of falling behind the pack.”

Ross said that whenever she sees opportunities for federal climate change grants, her first question is whether it’s possible to get one without state support.

“I’m like, ‘Is there a non-state option?’ And I keep encouraging anybody I can talk to at the federal level to have there be a non-state option,” she said.

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

The exterior of a Planned Parenthood Reproductive Health Services Center on May 28, 2019 in St Louis (Michael B. Thomas/Getty Images).

Missouri’s Planned Parenthood affiliates are asking the state administrative hearing commission to block a new law that prohibits the organization from being reimbursed for serving Medicaid patients. 

The law went into effect on Wednesday.

Nearly one in five Planned Parenthood patients in Missouri is insured through MO HealthNet, the state’s Medicaid program that serves low-income and disabled residents and has long banned funding for abortion.

The complaint to the Missouri Administrative Hearing Commission was filed after Missouri’s two Planned Parenthood affiliates say they received notifications of their termination from Medicaid, effective Wednesday.

“Despite an already overburdened health care safety net for Missouri Medicaid patients,” Planned Parenthood Great Plains and Planned Parenthood Great Rivers wrote in a joint press release, “lawmakers prioritized the legislative ‘defunding’ of Planned Parenthood this last session, harming Missourians with low incomes and forcing them to search for other providers.”

It’s the third — and Republicans hope final — attempt to end Medicaid reimbursements to any health centers affiliated with abortion providers.

Planned Parenthood alleges the state’s new restrictions violate federal Medicaid law, which protects patients’ right to choose their health care providers. 

The Missouri Department of Social Services, which oversees the state’s Medicaid program, said it doesn’t comment on pending litigation.

Abortion has been banned in Missouri since 2022, but Planned Parenthood clinics in Illinois and Kansas continue to perform the procedure. In Missouri, Planned Parenthood clinics provide services such as contraceptive care, STI testing, cancer screenings and wellness checks.

Missouri governor signs bill ending Medicaid reimbursements to Planned Parenthood

Critics of the law have argued it would primarily harm low-income Missourians who could be forced to find a new provider through the state’s already strained public health safety net if Planned Parenthood cannot foot the bill for these patients long-term. This could delay critical and potentially life-saving care.

In Missouri, women on Medicaid are 10 times more likely to die within one year of pregnancy than those on private insurance, according to an August multi-year report on maternal mortality published by the Missouri Department of Health and Senior Services.

“The impact of defunding efforts will only further destabilize Missouri’s fragile safety net,”  said Michelle Trupiano, executive director of Missouri Family Health Council in Monday’s press release, “by straining providers, extending wait times, and unnecessarily creating additional barriers for people accessing basic healthcare services.”

Planned Parenthood clinics in Missouri have been without Medicaid reimbursements for more than two years as prior attempts by Republicans to pass similar restrictions through the state budget were litigated and struck down in court. 

Planned Parenthood says it will continue to serve Medicaid patients despite the new law.

Some clinics, including Planned Parenthood Great Rivers, have offset the cost of care with private fundraising, according to the press release.

“Planned Parenthood’s doors remain open so patients can get the affordable, accessible care they rely on,” said Richard Muniz, interim president & CEO of Planned Parenthood Great Rivers, “as we challenge the state’s latest, illegal attempt to exclude us from participating in the Medicaid program.”

This story was updated Aug. 27 to add the Department of Social Services’ comment.

Students hold up anti-abortion signs at the Midwest March for Life on May 1 at the Missouri State Capitol (Anna Spoerre/Missouri Independent).

A pair of Republican state legislators and an anti-abortion activist filed a lawsuit Thursday asking a judge to block an abortion-rights constitutional amendment from appearing on the Nov. 5 ballot. 

State Sen. Mary Elizabeth Coleman, state Rep. Hannah Kelly and Kathy Forck sued last year challenging the cost estimate for a proposed constitutional amendment rolling back Missouri’s ban on abortion. 

The campaign behind the proposal ultimately turned in enough signatures to earn a spot on the November ballot, where it is set to appear as Amendment 3. 

Missouri voters will decide whether to legalize abortion in November 

On Thursday, Coleman, Kelly, Forck and Marguerite Forrest, the operator of a shelter for homeless pregnant women in St. Louis County, filed a new lawsuit in Cole Circuit Court arguing that the decision to place the amendment on the ballot should be reversed.

The amendment violates the Missouri Constitution, the lawsuit argues, because it illegally includes more than one subject. It also fails to specify the laws and constitutional provisions that would be repealed if it were approved by voters, the lawsuit argues. 

In a joint statement released to the media, the plaintiffs said Amendment 3 is a “direct threat to the lives of Missouri women by erasing the will of voters who chose to protect the safety of women and the child by electing strong pro-life leaders.”

Rachel Sweet, campaign manager for Missourians for Constitutional Freedom, which is supporting Amendment 3, called Thursday’s lawsuit “yet another baseless and desperate attempt from politicians to silence Missouri voters and prevent them from being heard. We will not let that happen.”

Sweet said she is confident the courts will “see through this thinly veiled effort to block Missouri voters and dismiss it swiftly.”

Missouri was the first state to ban abortion after the 2022 U.S. Supreme Court ruling overturning the constitutional right to the procedure. Since then, abortion has been virtually illegal, with limited exceptions only in cases of medical emergencies. There are no exceptions for survivors of rape or incest.

If approved by voters, Amendment 3 would legalize abortion up until the point of fetal viability, an undefined period of time generally seen as the point in which the fetus could survive outside the womb on its own, generally around 24 weeks, according to the American College of Obstetricians and Gynecologists. 

Such an amendment would return Missouri to the standard of the 1973 Roe v. Wade decision, which also legalized abortion up to the point of fetal viability. Missouri’s amendment also includes exceptions after viability “to protect the life or physical or mental health of the pregnant person.”

Missouri’s amendment also states that women and those performing or assisting in abortions cannot be prosecuted. Under current Missouri law, doctors who perform abortions deemed unnecessary can be charged with a class B felony and face up to 15 years in prison. Their medical license can also be suspended or revoked.

The lawsuit filed Thursday argues that Amendment 3 illegally includes more than one subject, in part because of its use of the phrase “fundamental right to reproductive freedom.” 

The lawsuit argues this phrase is “unlimited in scope” and is “systematically neutralizing all laws, existing or future, that attempt to limit this new, limitless ‘right to reproductive freedom.’” It lays out numerous restrictions on abortion and other laws that could be repealed by Amendment 3 if it were approved by voters, including restrictions on when abortions can be performed and bans on certain stem cell research. 

This story was updated at 2:35 p.m. with a comment from Missourians for Constitutional Freedom and at 3:11 p.m. to correct the spelling of Kathy Forck’s name. 

Helping a pregnant minor travel to get a legal abortion without parental consent is now a crime in two Republican-led states, and lawmakers in other states have considered similar legislation (Oscar Wong/Getty Images)

Helping a pregnant minor travel to get a legal abortion without parental consent is now a crime in at least two Republican-led states, prompting legal action by abortion-rights advocates and copycat legislation from conservative lawmakers in a handful of other states.

Last year, Idaho became the first state to outlaw “abortion trafficking,” which it defined as “recruiting, harboring or transporting” a pregnant minor to get an abortion or abortion medication without parental permission. In May, Tennessee enacted a similar law. And Republican lawmakers in Alabama, Mississippi and Oklahoma introduced abortion trafficking bills during their most recent legislative sessions, although those bills failed to advance before the sessions ended.

Those five states are among the 14 that enacted strict abortion bans following the U.S. Supreme Court’s June 2022 Dobbs decision, which dismantled the federal right to abortion. Now, conservative state lawmakers are pushing additional measures to try to restrict their residents from getting them in states where it remains legal.

“A lot of folks thought Dobbs was the floor and it’s really not,” said Tennessee state Rep. Aftyn Behn, a Nashville Democrat who’s challenging Tennessee’s trafficking law in court. “[Anti-abortion lawmakers] are coming for state travel and the ability to even talk about abortion.”

Abortion-rights advocates have filed lawsuits in Alabama, Idaho and Tennessee, arguing the laws are vague and violate constitutional rights to free speech and travel between states. A federal judge has temporarily blocked Idaho’s law from being enforced while the case is ongoing.

Proponents of the laws argue they’re needed to protect parental rights and to prevent other adults from persuading adolescents to get abortions.

“This is a parental rights piece of legislation,” Idaho Republican state Rep. Barbara Ehardt told Stateline. “We can’t control someone getting an abortion in Oregon. But you cannot take a child to get an abortion without the parent’s knowledge because, at least in the past, we would have called that kidnapping.”

But critics warn that abortion trafficking laws could have grave implications not only for interstate travel, but also for personal speech and communication between friends, or between children and adults they trust.

“If courts go down this road, it could change the scope of the First Amendment,” Mary Ziegler, a legal historian and law professor at the University of California, Davis School of Law, told Stateline. “It could have an effect on what else qualifies as crime-facilitating speech, and that could limit the kinds of things people can say and do online and in other contexts.”

Opponents also question whether states should be permitted to interfere in the business of other states. Criminalizing travel within an abortion-ban state to reach another state for a legal abortion would “allow prosecutors to project power across state lines,” said Ziegler.

“We haven’t seen states try to interfere in what’s happening in other states in quite the same way in a long time,” she said. “That’s why there is legal uncertainty — because we’re not talking about something where we have a lot of legal precedent.”

‘Parental rights’

Tennessee state Rep. Jason Zachary, a Knoxville Republican, defended Tennessee’s legislation as “a parental rights bill” that “reinforces a parent’s right to do what’s best for their child,” in remarks he made to the Tennessee General Assembly before the bill passed. Republican Gov. Bill Lee signed it into law in May.

The following month, Behn joined with Nashville attorney and longtime abortion access activist Rachel Welty to file a lawsuit challenging the new law.

Behn and Welty sued nearly a dozen district attorneys in Tennessee, alleging they ignored Welty’s requests to define what behavior would be deemed illegal under the new law. The Tennessee law says that abortion trafficking occurs when an adult “intentionally recruits, harbors, or transports” a pregnant minor within the state to get an abortion or an abortion-inducing drug without parental consent, “regardless of where the abortion is to be procured.”

A hearing to determine whether the court will grant a temporary injunction blocking the Tennessee law, which is currently in effect, is scheduled for Aug. 30.

After Idaho passed its law in April 2023, two advocacy groups and an attorney who works with sexual assault victims sued the state attorney general. The plaintiffs claim Idaho’s law is vague and violates the First Amendment right to free speech, as well as the right to travel freely between states. The right to interstate travel isn’t spelled out in the U.S. Constitution but it’s implied, legal experts say. The Idaho law directly applies to travel within the state, but it also notes that defendants are not immune from liability if “the abortion provider or the abortion-inducing drug provider is located in another state.”

Megan Kovacs, a board member with the Northwest Abortion Access Fund, which is a plaintiff in the case along with the Indigenous Idaho Alliance, said it is “so clearly unconstitutional to disallow people from accessing health care from within or outside their state.” Kovacs added that her group also wants to protect its volunteers from legal liability.

Neither the Idaho nor the Tennessee law exempts minors who become pregnant after being raped by a parent.

“If that person had to go to a parent who didn’t believe them or wanted to defend that family member who was the abuser, that only impedes healing even more,” said Kovacs, who has spent a decade working with survivors of domestic and sexual violence.

Ehardt, who sponsored the Idaho bill, said any adult who is told by a child about an incident of incest should call authorities rather than helping the minor obtain an abortion without parental consent.

“You have to call the police and they will be the ones to help protect the child’s safety,” she said.

The 9th U.S. Circuit Court of Appeals held a hearing in May in Seattle, and Kovacs said she expects to learn in the next few weeks whether the court will uphold the temporary injunction blocking Idaho’s law while the lawsuit rolls on.

In July 2023, a group of health care providers sued Alabama Republican Attorney General Steve Marshall and district attorneys, asking the court to prevent the state from prosecuting people who help Alabamians travel to get abortion care in states where it’s legal.

The providers filed the lawsuit in response to remarks that Marshall made on a radio show in 2022, when he suggested that some people who aid a pregnant person in planning or traveling to get an abortion in another state could be prosecuted under the state’s criminal conspiracy laws. A judge denied Marshall’s motion to dismiss the lawsuit earlier this year, and the case is ongoing.

A coordinated effort

The Tennessee and Idaho laws mirror language in model legislation that was published in 2022 by the National Right to Life Committee, which bills itself as the nation’s oldest and largest grassroots pro-life organization.

“With this model law, we [are] laying out a roadmap for the right-to-life movement so that, in a post-Roe society, we can protect many mothers and their children from the tragedy of abortion,” said Carol Tobias, president of National Right to Life Committee, in a June 2022 statement introducing the model anti-abortion law.

Anti-abortion-rights organizations, like other interest groups, have long coordinated strategies to promote their preferred legislation to state and federal lawmakers.

The Idaho and Tennessee laws focus specifically on minors, even though they comprise a small fraction of people who get abortions. Those under 19 accounted for 8.1% of abortions, and those under age 15 accounted for just 0.2% of abortions in 2021, the most recent year for which the federal Centers for Disease Control and Prevention has published data.

Kovacs and Ziegler say the bills zero in on minors’ access to abortion because policies that regulate children and teens tend to be more politically acceptable than broader restrictions that affect adults. Such bills also tend to be more likely to survive legal challenges in court.

A chilling effect

Nobody in Tennessee or Idaho has yet been prosecuted under the abortion trafficking laws, but an Idaho woman and her son were charged with kidnapping last fall for allegedly taking the son’s girlfriend, a minor, out of state to get an abortion.

One main goal of a law such as Tennessee’s, Behn believes, is to create a chilling effect so that average people are scared to help anyone who might need an abortion, for fear of breaking the law.

“These bills create an environment of suspicion, fear and misinformation,” said Behn. “But I do think we will see more aggressive district attorneys start to prosecute these cases. [The law] widens the permission structure to start prosecuting people.”

Laws criminalizing abortion travel and imposing other abortion restrictions may be designed to provoke a legal challenge, Ziegler said. With a 6-3 conservative majority, the U.S. Supreme Court might be inclined to support them.

Abortion-rights advocates argue that restrictive abortion laws end up harming even those people who live in states where abortion is still legal.

Oregon, for example, has some of the strongest abortion protection laws in the nation. And yet the strict abortion ban next door in Idaho has made it more difficult for Oregonians to access care, said Kovacs, who lives in Oregon.

Before Idaho’s ban, many people in Eastern Oregon traveled to Idaho for abortion care, she said, because its clinics were closer than Oregon’s clinics, most of which are concentrated on the western side of the state. Last year, in response to increasing abortion restrictions in other states, Oregon passed a sweeping health care omnibus bill that strengthens protections for abortion providers and explicitly allows minors to seek abortions without parental consent. It was signed into law and took effect in January.

Ziegler said it’s not hard to imagine that if abortion trafficking laws are upheld in abortion-ban states, at some point prosecutors in those states could file charges against providers in “safe” states for providing abortion help, such as mailing abortion pills.

“I think it’s not intended to just stop with the people who are in the ban states,” Ziegler said.

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

A crisis counselor answers a 988 call at the Ozark Center, which covers four southwestern counties (Photo courtesy of Freeman marketing).

Missouri has seen one of the nation’s largest increases in calls to the revamped national hotline that aids people facing mental health crises.

The number of calls to 988 from Missouri jumped 136% in May 2024 compared to May 2022, according to recent data from the health policy nonprofit KFF.

That’s a greater increase than the national average and ninth highest in the country.

State officials have celebrated Missouri’s volume increase as a product of significant efforts to ensure the public knows about 988.

“We are really proud of what we’re doing here,” said Jeanette Simmons, deputy division director of the Missouri Department of Mental Health’s Division of Behavioral Health, during a mental health commission meeting earlier this month. “In national meetings, lots of people ask us questions about our 988 efforts, and how we have had so much success, and how we’re doing it.”

She said they tell others they’re just “handing it out everywhere,” referring to outreach materials. 

The National Suicide Prevention Lifeline transitioned nationwide two years ago to the new three-digit 988 Suicide and Crisis Lifeline, which aims to be a comprehensive resource for people facing mental health, substance use and suicide crises. 

It’s part of a national effort to streamline access to services for mental health emergencies and craft a number that’s as easy and ubiquitous to remember as 911.

Last month, Department of Mental Health spokesperson Debra Walker said, Missouri’s 988 call centers answered more than 8,000 calls, 2,800 text messages and 600 chats.

The state answered 92% of calls at in-state call centers, which is above the national standard of 90%. 

The hotline directs calls based on callers’ area code to their nearest crisis center. When the in-state call centers are busy, the call is routed to the national phone line.

In July of 2022, around 12% of calls were abandoned before reaching someone on the other line.  That fell to 6% in 2024 despite the number of calls more than doubling in volume. 

The average speed to answer has decreased from 37 seconds in July 2022 to 19 seconds in July 2024, Walker added.

Walker said through the state’s training, strengthening partnership with community service providers and other partners, and prioritizing timely service, “Missouri has built an equitable and accessible crisis system.”

Going forward, the state will focus on continuing to educate people about 988 “with the  goal of reaching individuals most at risk for suicide and other negative mental health and substance use outcomes,” Walker said.

The federal government invested money for 988’s launch and rollout but requires states to establish long-term funding strategies. Missouri hasn’t passed legislation authorized by Congress to add a monthly fee to phone bills to help permanently fund the hotline and crisis services, similar to how 911 call centers are funded. 

So far, 10 states have added telecom fees.

And a report released in June by the national mental health nonprofit Inseparable found that although Missouri scores well in call center capacity, the availability of crisis mental health services is itself limited. The organization estimated the state would need 286 new short-term crisis residential beds to meet crisis stabilization needs, as well as 49 mobile response teams.

Syringes of COVID-19 vaccinations are filled during MU Health Care's vaccination clinic in the Walsworth Family Columns Club at Faurot Field in Columbia on Feb. 4, 2021 (Photo by Justin Kelley/MU Health Care).

WASHINGTON — The U.S. Food and Drug Administration on Thursday approved an updated COVID-19 vaccine intended to address severe symptoms of the virus ahead of the cold and flu season.

The new booster shots from Moderna and Pfizer follow a summer of increasing COVID-19 cases and are designed to better address the variants that are circulating now.

Peter Marks, director of the FDA’s Center for Biologics Evaluation and Research, said in a written statement that vaccination “continues to be the cornerstone of COVID-19 prevention.”

“These updated vaccines meet the agency’s rigorous, scientific standards for safety, effectiveness, and manufacturing quality,” Marks said. “Given waning immunity of the population from previous exposure to the virus and from prior vaccination, we strongly encourage those who are eligible to consider receiving an updated COVID-19 vaccine to provide better protection against currently circulating variants.”

Wastewater surveillance has been steadily increasing since early May and could rise further now that children throughout the country are returning to school.

The number of emergency department visits began increasing in May as well. And while the death rate from COVID-19 steadily decreased during the first half of the year, it began ticking up slightly in June, according to data from the Centers for Disease Control and Prevention.

The FDA announcement said that three doses of the updated Pfizer-BioNTech vaccine or two doses of the updated Moderna vaccine are approved for unvaccinated children between six months and 4 years old.

Children between six months and 4 years old who have already received their COVID-19 vaccine are eligible to receive one or two doses or either updated vaccine. The dosing will depend on the timing and number of doses of their previous vaccination.

Children between 5 and 11 years old can receive a single dose of the updated vaccine, regardless of whether they’ve been previously vaccinated or not. If a child in that age range has been vaccinated against COVID-19, they need to wait at least two months before getting the updated dose.

Anyone over the age of 12 is eligible for a single dose of the updated vaccine if they’ve been vaccinated previously. They also must wait at least two months after their last vaccination.

Pfizer wrote in a statement that its “vaccine will begin shipping immediately and be available in pharmacies, hospitals, and clinics across the U.S. beginning in the coming days.”

Moderna said it expects its updated vaccine “to be in pharmacies and care settings in the coming days.”

Missouri's Department of Mental Health building in Jefferson City (Annelise Hanshaw/Missouri Independent).

The number of people languishing in Missouri jails in need of court-ordered mental health treatment currently stands at 344 — and the wait time for a hospital bed averages one year. 

That’s up from 254 people this time last year, according to Missouri Department of Mental Health data provided to The Independent. A spokeswoman for the department said that because the agency’s inpatient beds are at capacity, the number of people waiting in jails for treatment will continue to rise.

Debra Walker, the department’s spokeswoman, said February was the first month the number of individuals waiting ever exceeded 300.

None of the people on the waitlist have been convicted of a crime. They were arrested, found incompetent to stand trial and ordered by the court into mental health treatment, designed to allow them to stand trial, a process called competency restoration that generally includes therapy and medication. 

“We do want to increase the number of individuals who are getting competency restoration,” said Jeanette Simmons, deputy division director of the Missouri Department of Mental Health’s Division of Behavioral Health, during a mental health commission meeting earlier this month. “We have a growing number of individuals who are waiting for those services.”

Missouri has faced a years-long struggle with this issue, due to increasing numbers of court referrals for competency restoration, staffing issues and limited psychiatric hospital capacity. It’s worsened over the last year.

The legislature appropriated $300 million this year for Department of Mental Health to open a new hospital in Kansas City, but it could be around five years before construction is complete.

State officials are also working to implement the “jail-based competency restoration” program approved by the legislature this year in response to the issue. This year’s budget set aside $2.5 million for the jail-based competency programs to be established in jails in St. Louis, St. Louis County, Jackson County, Clay County and Greene County.

Services in jail-based competency restoration will include room and board, along with medical care for 10 slots at each jail, contracted staff from a local behavioral health organization, and psychiatric care from “mobile team practitioners.”

The department is currently training two agencies in Kansas City that will be going into county jails to provide jail-based treatment. Clay County has a “tentative go live date” for September, Simmons said.

“So we're really looking forward to that and getting that launched, because we do believe that it's going to take a multifaceted approach to target those numbers,” she said.

Simmons said the agency has mobile teams of doctors going into county jails prescribing medications “to try and get folks started on those medications that they need to stabilize their mental illness.” The department is working with community behavioral health liaisons as well as jail mental health or medical staff, she said, to get people services.

The Department of Mental Health is also working on trying to get information to the courts about outpatient restoration, for those who can be safely treated in the community and don't require hospital-level care. A law passed this year gives the agency the authority to treat certain arrested people on an outpatient basis.

“Sometimes I think the courts don’t really consider that as an option,” Simmons said of outpatient treatment. “It’s something very new.”

In other states, including some bordering Missouri, lawsuits have been filed over similar wait times, alleging they violate individuals’ rights to due process and the Americans with Disabilities Act.

A federal lawsuit filed last year in Oklahoma alleged jails are holding patients for three months to one year. A proposed settlement set a benchmark of a 60 day maximum wait and ultimately a goal of 21 days, but it has faced opposition from the governor.

A lawsuit filed in Kansas in 2022 alleged that individuals are detained for longer waiting for a psychiatric bed than they would be if they had been convicted. Many of the charges are for low-level crimes, national investigations have found.

County sheriffs and jail administrators in Missouri have raised the alarm about challenges caring for individuals who are being detained pretrial. And state officials have acknowledged the long waits contribute to mental deterioration.

The Missouri Sheriffs’ Association recently published an issue of their ‘Missouri Jails’ magazine focused on managing mental health challenges in county jails, which shared several examples of local issues, including that one county spent $30,000 to provide around-the-clock guarding over a suspect for two months, because the secure medical centers didn’t have any openings.

Some county sheriffs are looking to build or expand jails to combat the issue, according to the magazine, including by increasing the number of solitary cells to keep those with mental health diagnoses out of the general population. Others have contracted with private health provider Turn Key Health Clinics to provide increased mental health care while people are awaiting transfer. 

“As mental health professionals and legislators struggle to find solutions to the crisis,” magazine contributor Michael Feeback wrote, “sheriffs and other agencies are looking for answers on their own.” 

Roundup’s manufacturer, the multinational Bayer, has faced myriad lawsuits related to the weed killer. Roundup’s main ingredient likely causes cancer, according to numerous reports and studies (Scott Olson/Getty Images)

Agribusiness giant Bayer won a legal victory last week in long-running litigation over whether its popular Roundup pesticide has caused cancer.

The case started in 2019, when a husband and wife in Pennsylvania sued Missouri-based Monsanto, which Bayer purchased in 2018, and alleged the company had violated state law by not including a cancer warning label on Roundup. The U.S. Environmental Protection Agency, which regulates pesticides, did not make the company add such a warning.

On Aug. 15, the U.S. Court of Appeals for the Third Circuit, based in Pennsylvania, ruled the federal law governing pesticides — the Federal Insecticide, Fungicide, and Rodenticide Act, or FIFRA — requires “nationwide uniformity” over pesticide regulation. The state of Pennsylvania did not have authority in the case, the court decided.

The appeals court decision in Pennsylvania conflicts with another decision made earlier this year in Atlanta, according to the St. Louis Business Journal.

In February, the U.S. Court of Appeals for the 11th Circuit ruled FIFRA did not preempt state law. Georgia’s law on warning residents about possible harms from pesticides was “fully consistent with” the federal law, according to the Business Journal.

Because the decisions conflict with each other, that could lead to the U.S. Supreme Court stepping in, according to Reuters.

Bayer told Reuters the Supreme Court should “settle this important issue of law.”

In 2020, Bayer settled most of its Roundup litigation for about $10 billion, but some cases still remain active. After news of the legal victory, Bayer’s stock price surged, according to Bloomberg. It had been slumping over the past year.

This article first appeared on Investigate Midwest and is republished here under a Creative Commons license.

In Missouri, 490,000 kids are estimated to receive benefits amounting to $58.8 million (John Moore/Getty Images).

Missouri’s social services agency announced Monday that it is officially launching a federal food program that could provide aid to over 400,000 kids in the state.

Each eligible child will receive a one-time benefit of $120, loaded onto a card that can be used like a debit card to buy groceries.

It’s part of a permanent federal program in its first year of existence called Summer Electronic Benefits Transfer, or SUN Bucks. The program aims to help kids who receive subsidized school meals avoid a summer drop-off in nutrition.

The money was intended to be distributed during the summer break. But state officials said they dealt with technical issues that delayed federal approval and hindered earlier launch of the program.

The Missouri Department of Social Services, which will oversee the program, did not lay out a timeline for dispersing the benefits, and a spokesperson didn’t respond to questions.

The following groups of kids are automatically eligible, and their families will not need to apply for benefits: 

• Students who are eligible for free or reduced-price lunch during the school year,
• Households already enrolled in Supplemental Nutrition Assistance Program (SNAP) or temporary assistance,
• And students who are in foster care, are experiencing homelessness or are migrants.

Those benefits will be issued on an existing card if the family is enrolled in SNAP benefits or temporary assistance, or on a new mailed card if they are not. Families who need a new EBT card can request one by phone or the ebtEDGE mobile app.

Families who are not automatically eligible must submit an application online by Aug. 31. The state’s eligibility navigator will tell families whether they must apply.

Even with the department announcing that money was set to be distributed, it warned in its press release that “delays in issuing benefits are possible.” 

Benefits will expire 122 days after they are issued, regardless of usage, so families must act quickly once the benefits are distributed. They should also keep the cards for next summer’s program, the state’s website advises.

Food security advocates in the state were relieved when Missouri opted into the program after weighing factors like technology issues and staffing.

Thirteen Republican-led states opted out of the program entirely this year.

The program is run through the U.S. Department of Agriculture and the benefits are fully federally funded. The state shares one-half of the administrative cost. DSS is leading Missouri’s administration, with the help of the Department of Elementary and Secondary Education.

In Missouri, 490,000 kids are estimated to receive benefits amounting to $58.8 million.

“Although we had to face some difficult challenges,” Director of Family Support Division Kim Evans said in the press release, “I am proud of our team members who worked diligently with our state and federal partners to get this important program off the ground. 

“We will be much more prepared for next summer when we anticipate a smoother rollout and even greater success,” Evans said.

A similar, temporary program called Pandemic EBT provided various benefits during the pandemic and was beset with administrative issues — particularly because it required a new data collection portal to collect and share eligible students’ information with two agencies in the state. 

The benefits designed to cover food costs during the summer of 2022 did not start going out until June 2023, and Missouri declined to participate in the summer 2023 program because of those issues — forgoing at least $40 million in aid.

(Joe Raedle/Getty Images)

Last month, the Federal Trade Commission released a scathing report suggesting that pharmacy benefit managers, the middlemen in the drug supply chain known as PBMs, are “profiting by inflating drug costs and squeezing Main Street pharmacies.”

The FTC found that because of consolidation in the industry, the three largest PBMs now manage nearly 80% of all prescriptions filled in the United States. PBMs use that power, the agency concluded, to raise drug prices, control patients’ access to them, and steer people away from independent pharmacies and toward the pharmacies they own.

A week after the FTC released its report, Vermont filed a lawsuit against CVS, Evernorth Health Services (a subsidiary of insurance giant Cigna) and nearly two dozen affiliated entities, claiming they have “distorted the market to their benefit at the expense of Vermont patients” and the state. The PBMs, the suit claims, “are driving up drug prices and foreclosing patients’ access to life-sustaining treatments in order to increase their profits.”

Vermont was the first state to file a lawsuit specifically citing the FTC report, but it probably won’t be the last.

States increasingly have been turning to lawsuits against PBMs in their drive to lower prescription drug prices. They’ve done so partly because of the barriers they’ve faced in trying to address the problem through legislation, including fierce lobbying by PBMs and a federal law that prevents them from helping the two-thirds of Americans who get their health coverage through their employers and so-called self-funded plans.

In taking their fight to courthouses, states also are turning the tables on corporations that have used lawsuits to block legislative attempts at regulation.

“Pharmaceutical companies themselves have a scorched-earth policy towards any legislative or regulatory changes. In other words, the industry will throw every claim it can think of at the states to try to block implementation of the law,” said Robin Feldman, a professor at UC Law San Francisco and an expert on pharmaceutical law.

State legislators and policymakers “have decided that if [their laws] are going to end up in court, perhaps they might have their own claims to bring,” Feldman told Stateline.

In the past couple of years, Arizona, Hawaii, Indiana, Kentucky, Ohio and Utah have sued PBMs, and complaints from dozens of states and municipalities across the country have been consolidated into multidistrict litigation in New Jersey.

And in June, 32 state attorneys general and five pharmacist trade groups joined a lawsuit in support of an Oklahoma law that would place tough new regulations on PBMs — but which the companies have blocked in court.

Illinois Democratic state Sen. Laura Fine, who serves on the Health and Human Services Committee and has pushed for new regulations on health care companies, said she has been frustrated by the limitations of legislation.

“I’m glad that we have attorneys general who will take on these issues and these causes on behalf of the people in our state,” Fine told Stateline. “I think it’s an important tool in the toolbox for everyone to know that if we cannot accomplish what needs to get done, we have our attorneys general behind us to make sure that they can be out there to protect the consumer.”

Major players

As intermediaries in the drug supply chain, PBMs determine which drugs are available under a person’s insurance plan, set copayments and decide how much pharmacies must pay to acquire drugs.

The PBMs argue that they use their bargaining power to negotiate lower drug prices for consumers and pharmacists. They blame drug manufacturers — often known as Big Pharma — for prices that are higher in the United States than anywhere else.

Greg Lopes, vice president of public affairs and communications for the Pharmaceutical Care Management Association, a trade association representing PBMs, wrote in an email to Stateline that “any notion that PBMs are increasing prescription drug costs is patently false.”

“Employers choose to hire PBMs because they have a proven track record of lowering drug costs for health plan sponsors, which translates to lower premiums and lower out-of-pocket costs for patients,” Lopes wrote. “PBMs protect the ability of employers to offer quality health coverage by serving as the only check against Big Pharma’s unlimited pricing power.”

David Winthrop, vice president of external affairs at CVS Health, which owns the PBM CVS Caremark, said the company “is proud of the work we do to make medicine more affordable for American businesses, unions and patients.”

“Any policies that would limit PBM negotiating tools would instead serve as a handout to the pharmaceutical industry, leaving those who pay for prescription drugs at the mercy of the prices drugmakers set,” Winthrop said.

The Federal Trade Commission sees the problem differently.

It notes in its report that CVS Caremark is among the three major players that dominate the PBM landscape, along with Express Scripts and Optum Rx. Express Scripts is a subsidiary of Cigna, and Optum Rx is owned by UnitedHealth. Together, the FTC asserts, the three companies use their supremacy to “wield enormous power and influence over patients’ access to drugs and the prices they pay.”

“This can have dire consequences for Americans, with nearly three in ten surveyed Americans reporting rationing or even skipping doses of their prescribed medicines due to high costs,” the FTC report states.

The agency also notes that PBMs harm independent pharmacies, “who struggle to navigate contractual terms imposed by PBMs that they find confusing, unfair, arbitrary, and harmful to their businesses.” Between 2013 and 2022, the report states, about 10% of independent retail pharmacies in rural America closed.

“Health plans and PBMs are often just trying to protect the status quo as it remains today, for obvious reasons, because the environment has benefited them significantly,” said Antonio Ciaccia, CEO of 46brooklyn Research, a nonprofit that studies drug pricing data.

Daniel Aaron, an associate professor at the S.J. Quinney College of Law at the University of Utah who specializes in health care policy, pointed out that pursuing litigation allows states to sidestep PBMs’ lobbying power in legislatures.

Aaron argued that legislation and litigation can work in tandem.

“Lawsuits can actually help form policy,” Aaron said in an interview. “And because these lawsuits attract a lot of attention and capture the public interest and expose a lot of documents, they can actually buttress policymaking and attract even more public attention.”

He also noted that by taking on unpopular defendants, state attorneys general can raise their political profiles — and many of them aspire to be governors.

Ben Widlanski, the co-lead attorney in a lawsuit involving insulin prices, agreed that lawsuits are valuable because they shine a light on companies’ conduct in a way that state and federal regulators have been unable to do.

“Because there’s not a lot of oversight and because the government agencies responsible for it have not really been doing their jobs for a very long time, the only immediate response that has any chance of making a difference is litigation,” said Widlanski, a partner at Florida-based Kozyak Tropin & Throckmorton.

In suing large corporations, state attorneys general often hire outside law firms on a contingency fee basis.

The limits of litigation

Aaron said successful lawsuits “can hold parties accountable, at least in theory, for illegal conduct and for causing harm. It can increase the cost of engaging in illegal conduct by making that conduct more expensive.”

But Ron Howrigon, a former Cigna executive, cautioned that using litigation to rein in deep-pocketed corporations isn’t as effective as enacting strong laws — however difficult that might be. Howrigon said many large health corporations consider expensive legal settlements to be merely the cost of doing business.

“I don’t think they’re really necessarily worried that the individual litigation is something that’s going to shut it down,” said Howrigon, who is now president and CEO of Fulcrum Strategies, a firm specializing in insurance contracts. “As a friend of mine put it, it’s putting ‘Band-Aids on bullet wounds.’”

What health care corporations are really scared of, Howrigon said, are sweeping policy changes.

“If I’m an insurance company, I’d much rather pay millions of dollars in fines than have a new law that I have to comply with going forward,” he said. “So, I’m not going to say that lawsuits don’t have any impact. But they don’t have nearly the impact as what legislative change would have.”

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

Students hold up anti-abortion signs at the Midwest March for Life on May 1 at the Missouri State Capitol (Anna Spoerre/Missouri Independent).

Planned Parenthood Great Plains CEO Emily Wales, left, and health care manager Logan Rink answer questions during an Aug. 16, 2024, interview in the Pittsburg Planned Parenthood clinic (Grace Hills/Kansas Reflector).

PITTSBURG, Kan. — A new Planned Parenthood clinic opening Monday in southeast Kansas will be the closest abortion access point for many people in the South and expects to have patients from six states in its first five days — Kansas, Missouri, Oklahoma, Arkansas, Texas and Louisiana.

Kansas saw a 369% increase in abortions in 2023, with 69% of patients coming from out of state, according to the Guttmacher Institute. For the Trust Women Clinic in Wichita, which was previously the closest city for abortion access for Southern states, 81% of patients were from out of state, with Texas the most common home state, followed by Oklahoma.

Texas and Oklahoma have total abortion bans, with few exceptions. Southern states have six-week abortion bans. On average, pregnant people know they are pregnant after 5.2 weeks for intendent pregnancies and 7.2 weeks for unintended pregnancies, the National Library of Medicine found.

The Pittsburg clinic will offer medication abortions for up to 11 weeks of pregnancy, and surgical abortions for 14-15 weeks of pregnancy.

But, there will be a delay before the clinic offers surgical care.

“We have excellent trained staff to offer this care,” said Emily Wales, president and CEO of Planned Parenthood Great Plains. “But we also know it’s a transition for the community and for us to launch a new center here, so it’ll probably be a little bit of time before we’re offering procedural care.”

Why Pittsburg?

Wales said a key factor in the Pittsburg location was access to Southern states. And she pointed out that Kansas already is well versed in providing abortion care to people from Missouri and other states. Pittsburg is about five miles from the Missouri border.

A 2018 law in Missouri banned abortion after 15 weeks, meaning Kansas had been absorbing Missouri patients for four years before the U.S. Supreme Court declared in Dobbs v. Jackson Women’s Health Organization that the Constitution does not confer a right to abortion.

The 2022 Dobbs decision felt like “dominos falling,” Wales said.

“We are doing everything we can to meet the need,” Wales said. “But we’re also not trying to hide the fact that there are far more people calling than we can actually get in.”

Wales also said there was a need for the services Planned Parenthood offers — which go beyond abortion care — in southeast Kansas. Patients from the Pittsburg area were traveling roughly two hours to Overland Park to receive care.

While more than 60% of Crawford County voters in 2020 supported Donald Trump, the president who packed the Supreme Court with anti-abortion justices, they voted against the proposed constitutional amendment that would have removed the right to terminate a pregnancy in Kansas.

Logan Rink, a Pittsburg native and the health care manager of the Pittsburg clinic, said she has heard positive feedback from the community. She said Planned Parenthood will meet needs that weren’t being met, and that the community views it as a great resource.

Anti-abortion protesters frequent the other Planned Parenthood locations in Kansas, attempting to stop patients from receiving an abortion.

Wales said Planned Parenthood typically sees protests when it opens a new location, but they “die down after a while.”

Members of Lighthouse church, a nondenominational anti-abortion Christian church in Pittsburg, spoke in opposition of the clinic at the May 28 city commission meeting.

“I know this is a major issue in our culture, abortion, but the reality is there’s no safe abortions because you start out with two lives and you end with one life,” said Pittsburg resident Shawn Osbeen.

Another resident, Susan Powers, also opposed the clinic, but she said this “may be a wakeup call” for the church and community to provide more support for pregnant people.

The commissioners stayed neutral on the opening of the clinic.

In 2009 in Wichita, George Tiller, one of only a few doctors in the nation who performed late-term abortions, was murdered in the foyer of his church. Planned Parenthood has a rigid security protocol in place, with security officers on site, but the shadow of Tiller’s death remains.

“The time it comes up the most, really, is when we are talking to potential providers or physicians who might be interested in staff roles,” Wales said. “They have questions about what the communities are like, what the protesters are like. We are fortunate to have not had that kind of violence at our health centers.”

Patients from the South 

The National Library of Medicine found that people from a lower socioeconomic status are more likely to receive an abortion, and extra time away from work adds up. For patients traveling from the South, the Pittsburg clinic will be more than two hours closer than clinics in Wichita.

“If we can cut off two hours one way, then two hours coming home, that’s a tremendous difference for a lot of our patients,” Wales said.

Planned Parenthood provides assistance to patients who need it. Before Dobbs, 80% of its patients didn’t need assistance, and 20% did. Now, Wales said, the percentages have flipped and the assistance they provide looks “entirely different.”

“So many people now have to go so far from home,” Wales said. “People could maybe get two hours from home, but telling patients it’s going to be 10 or 12 hours is impossible for a lot of people.”

The Pittsburg location will provide support for patients who can’t afford the journey. Kansas law allows abortions up to 22 weeks after the last menstrual period, but the Pittsburg clinic won’t have the resources to provide abortions that far into a pregnancy. If needed, the clinic will offer transportation to the Overland Park location, where procedural abortions are offered up to 21 weeks and 6 days into the pregnancy.

Lawsuits in Texas have threatened people traveling to receive abortions. These lawsuits violate the interstate commerce clause in the U.S. Constitution and may not be enforceable, but they caused a stigma, Wales said.

“It is heartbreaking to me that we have patients who do come to us and say they didn’t tell their friends or family, even though they knew that they would be supportive of their decision, because they didn’t know if it was legal in their home state to talk about the fact that they were leaving to seek care,” Wales said.

Wales sees a perception that patients believe they can’t travel or talk about abortion. She says they worry about what would happen to their kids, their partners, and their careers.

Issues to watch 

Vice President Kamala Harris has made abortion access a cornerstone of her presidential campaign, and if elected she has promised to codify Roe v. Wade, which would legalize abortion nationally.

Missourians will vote on their abortion rights in November. Each time abortion rights are placed on local ballots, the right to choose an abortion has won.

But, even if the movement to secure abortion rights prevails in November, access for every American would take decades, Wales said.

There are multiple lawsuits and legislation in Kansas attempting to restrict abortion access, despite Kansans rejecting the proposed constitutional amendment to eliminate abortion rights in 2022. Planned Parenthood has fought back on these attempts.

“Kansans are saying we want medical care to be private, and not in the hands of the Legislature,” Wales said. “The state passed additional requirements this year where we would have to ask patients invasive and shaming questions that have nothing to do with why they get care or how we deliver care. And so we are challenging that on behalf of our patients.”

This story was originally published by Kansas Reflector, a States Newsroom affiliate. 

(Emily Elconin/Getty Images).

Last year, when COVID vaccines were still free, barely one in five Americans rolled up their sleeves for the latest dose.

Now that some people will have to pay $100-plus for the shot, health officials expect even weaker demand when the next version of the vaccine comes out this fall.

Meanwhile, a surprisingly strong summer surge of COVID cases sweeps across Kansas and Missouri.

As students head back to school, more people are testing positive, ending up in emergency rooms and getting hospitalized with the virus, according to the U.S. Centers for Disease Control and Prevention.

In Kansas City, the reported case rate at the end of July was more than double the same week last year and edging toward last winter’s rate. At the same time, wastewater testing in Kansas and Missouri showed viral activity that surpassed national and regional levels.

Of course, the virus is nothing like it used to be. At the height of the pandemic in January of 2021, the CDC reported that almost 30% of weekly deaths in the U.S. could be attributed to COVID. For the week of Aug. 3, the disease was blamed for 1.5% of U.S. deaths.

But the picture would look quite different without the vaccine, experts said. At the same time, some health professionals trace August’s surge to low vaccination rates last September and October.

“The urgency of COVID has obviously gone down,” said Cecelia Thomas, a health policy consultant with Washington-based Venn Strategies. “People are now getting it or they’re seeing people get it and it’s like a cold. Not even a bad cold. But I don’t think they’re realizing that it’s not as bad because they are vaccinated.”

Immunity wanes over time as the virus mutates. Getting an updated COVID shot every year, doctors advise, helps your immune system keep pace with changes. But last year, as life seemed to have returned to normal for most people, many Americans took a pass on the COVID shot.

At the start of December, the height of vaccine season, only 16% of adults had gotten the updated shot. The rate had only ticked up to 22.5% by the middle of May.

Surprise summer surge

Scientists have come to expect a summer rise in COVID cases because the virus is cyclical, ebbing and waning in temperate climates as seasons change. But the current COVID surge has caught some health experts by surprise. It’s infecting more people and sending more patients to hospitals.

Dr. William Schaffner, a professor of infectious diseases at Vanderbilt University Medical Center, blames the higher than expected number of cases on last year’s lackluster vaccination rates.

“Many of the people being hospitalized today did not receive the vaccine last fall,” he said.

Hospitals no longer report the number of patients admitted with COVID. But at least anecdotally, doctors say, they’re seeing more people getting sick with the virus. And some people most at risk are getting really sick.

Dr. Dana Hawkinson, an infectious-disease doctor at the University of Kansas Health System, said people should be aware of the current risk, especially if their age or underlying health puts them at higher risk for getting severely ill.

“Have a plan,” he said, “especially if you are at high risk.”

That can include wearing a mask in crowded places, being careful about hand hygiene, avoiding touching your eyes, nose and mouth when in public and, of course, getting up to date on your vaccine.

An updated COVID vaccine, recommended annually for anyone 6 months and older, can prevent severe illness and reduce the chances that you’ll end up with long COVID.

But getting a current vaccine is about to get a lot harder, especially for patients who are uninsured.

COVID vaccines will likely cost more this fall

During the height of the pandemic, COVID vaccinations were free to everyone. People only needed to sign up for an appointment online and walk into a nearby pharmacy. No cash needed.

When the federal government lifted the Public Health Emergency in May of 2023, people covered by Medicare or Medicaid and most people with private insurance could still get the shot without paying a copay. People without insurance got free shots through the $1 billion federal Bridge Access Program.

That was meant to cover the gap so all COVID shots remained free through the end of 2024. In the meantime, the CDC promised to establish a new program to make sure uninsured adults could continue getting free COVID vaccines. It was to be modeled after the federal Vaccines for Children program, which pays for vaccines for minors whose families can’t afford them.

But that program hasn’t come to fruition. And, thanks to congressional budget cuts, funding for the Bridge Access Program is running out early. Meanwhile, people with private insurance may have to pay a copay to get the shot.

For someone without insurance, the shot can cost more than $100. The Johnson County Department of Health and Environment’s website lists the out-of-pocket cost for a COVID shot as $160.

Even when a shot is covered by insurance, many health departments charge an administration fee. In Johnson County and for the Wyandotte County Public Health Department, that amounts to $20 for COVID or any other vaccine.

Vaccine access will vary by health department

Public health officials around the Kansas City area are varied in how they plan to handle the lack of federal funding for COVID shots.

The Wyandotte County Public Health Department won’t offer any free COVID vaccines for adults this fall. Jackson County Public Health has allocated American Rescue Plan funds to cover the cost of offering free vaccines to uninsured adults through the end of the year. And Platte County is weighing how to allocate expected state funding for COVID and flu vaccines.

Money won’t stretch as far if the county chooses to offer the COVID shot, which is much more costly than the flu vaccine, said Aaron Smullin, Platte County Health Department spokesman.

“We are evaluating data on COVID/flu hospitalizations and deaths to decide how to allocate our resources,” Smullin wrote in an email response. “Without current (Bridge) funding, we face the difficult choice of whether to immunize 500 people against flu or 125 against COVID.”

Public health officials fear that any added expense and complication will lead many people to forego the shot again this fall. And that could mean more infections and hospitalizations during future a COVID surge.

The current strains of COVID infecting most people this summer — known as FLiRT variants — are related to Omicron, the version of the virus that swept across the world in late 2021. The variants are highly contagious and spread readily.

They are also still mild for most people who test positive. That’s because most people have immunity, either from previous infections or from getting the vaccine. But the evolving virus could still become more dangerous again, scientists said, which is why vaccines are so important.

“These vaccines have saved millions of lives around the world, including in the United States,” Schaffner said. “But you can’t get protected if the vaccine is in the refrigerator. It’s got to be in your arm to work.”

In addition to getting vaccinated, public health officials warn that people should test if they have symptoms and isolate and take other precautions like wearing a mask to avoid spreading the virus if they get sick. When someone tests positive, a doctor can prescribe an antiviral medication to prevent severe disease.

No-cost testing is still available at some pharmacies for people without insurance who have been exposed to COVID or have symptoms. And people who are infected, can apply for free access to antiviral medication treatments like Paxlovid.

This article first appeared on Beacon: Kansas City and is republished here under a Creative Commons license.

Ten of 24 people injured by bullets at the Kansas City Chiefs Super Bowl parade were under 18 years old. Countless more children experienced the trauma firsthand. Gabriella Magers-Darger (left) was burned by sparks from a ricocheted bullet. Samuel Arellano was shot in the side (Christopher Smith for KFF Health News).

Six months after Gabriella Magers-Darger’s legs were burned by sparks from a ricocheted bullet at the Kansas City Chiefs Super Bowl parade in February, the 14-year-old is ready to leave the past behind.

She is dreading the pitfalls of being a high school freshman, even as she looks forward to being back with friends and at color guard, dance, and volleyball. She might even join the wrestling team to get some respect at school.

But the past remains ever present.

At a July Fourth gathering, a family friend brought noise-canceling headphones in case the fireworks became too much. Earlier in the summer Gabriella had a hard time viewing a relative’s gun collection, the handguns in particular. And she hyperventilated when she saw a family friend’s finger after it was sliced by accident — the sight of blood reminds her of seeing a fatally wounded Lisa Lopez-Galvan minutes after she was shot outside Union Station, the only person killed that day.

Her mom, Bridget Barton, said Gabriella has had a chip on her shoulder since the parade.

“She’s lost some softness to her, some gentleness to her,” Barton said.

Children are particularly vulnerable to the stresses of gun violence, and 10 of 24 people injured by bullets at the Feb. 14 parade were under 18 years old. Countless more children like Gabriella experienced the trauma firsthand. They’ve endured fear, anger, sleep problems, and hypersensitivity to crowds and noises.

A 15-year-old girl who was shot through the jaw and shoulder effectively dropped out of school for a time and daily panic attacks kept her from summer school, too. An 11-year-old boy shot in the side described feeling angry at school for reasons he couldn’t explain. A 5-year-old girl who was on her father’s shoulders when he was hit by gunfire panics each time her dad feels sick, fearing he has been shot again.

“She’s not the same kid. I mean, she’s definitely not,” said Erika Nelson, mother of the 15-year-old, Mireya, who has scars on her jaw and face. “You never know when she’s going to snap. You never know. You might say something or someone might bring up something that reminds her of that day.”

Guns overtook motor vehicle accidents as the leading cause of death for children in 2020, but a far higher number of kids are hit by gunfire and survive. Research suggests that kids sustain nonfatal firearm injuries anywhere from two to four times more often than they are killed by guns.

Scientists say the long-term effects of gun violence on kids are little researched and poorly understood. But the harm is pervasive. Harvard and Massachusetts General Hospital researchers found that during the first year after a firearm injury, child survivors experienced a 117% increase in pain disorders, a 68% increase in psychiatric disorders, and a 144% increase in substance use disorders. The mental health effects spill over — to mothers, fathers, siblings.

For many affected by the shooting in Kansas City, Missouri, the triggers began right away.

‘I get mad easily’

Just 10 days after Samuel Arellano was shot at the parade, he attended another big sporting event.

Samuel was invited to attend a University of Kansas men’s basketball game at Allen Fieldhouse in Lawrence. During a break in the game, with a video camera pointed at Samuel and his parents, former KU star Jalen Wilson appeared on the scoreboard and addressed him directly.

“I heard about your story,” Wilson, who now plays in the NBA, said on the big screen. “I’m so very thankful that you are here today and it is a blessing that we can have you to give you the love and support you truly deserve.”

Wilson asked the 16,000 fans in attendance to stand and give Samuel a round of applause. As the crowd clapped and an announcer bellowed about him being a “brave young man,” Samuel looked at his parents, then down at his feet, smiling shyly.

But minutes later when the game resumed, Samuel started to cry and had to leave the auditorium with his mom, Abigail.

“When it got pretty loud, that’s when he started breaking up again,” his dad, Antonio, said. “So she had to step out with him for a minute. So any loud places, if it’s too loud, it’s affecting him.”

Samuel, who turned 11 in March, was shot in the ribs on his right side. The scar on his back is barely noticeable now, but lingering effects from the parade shooting are obvious. He is seeing a therapist — as is his father, though Abigail has had a tough time finding a Spanish-speaking one and still hasn’t had an appointment.

Samuel had trouble sleeping in the first weeks after the shooting and often crawled in bed with his mom and dad. He used to get good grades, but that became more difficult, Abigail said. His personality has changed, which sometimes has shown up at school.

“I get mad easily,” Samuel said. “I [have] never been like this before but like, if they tell me to sit down, I get mad. I don’t know why.”

Traumatized children often have difficulty expressing emotions and may be given to outbursts of anger, according to Michelle Johnson-Motoyama, a professor of social work at Ohio State University.

“I’m sure for that child there is a sense of tremendous injustice about what happened,” Johnson-Motoyama said.

Especially right after the shooting, Samuel had panic attacks, Antonio said, and he’d break out in a sweat. Therapists told them that was normal. But the parents also kept him off his phone for a while, as there was so much about the shooting on the news and online.

Abigail, who works at a car dealership with Antonio, is anxious about seeing her son change, his suffering and sadness. She is also concerned for her three daughters, a 16-year-old and 13-year-old twins. Her father, Victor Salas, who was with Samuel at the parade, was also reeling in its aftermath.

“I’m crying and crying and crying about what happened,” Salas said in Spanish four days after the parade. “Because it was chaos. It doesn’t mean that families don’t love their family, but everyone took off to save their own lives. I saved my grandchildren’s lives, but what happens to the rest of the people? We’re not prepared.”

On the good side, Samuel felt very supported by the community in Kansas City, Kansas. Many people from his school stopped by in the first few days to visit, including friends and even a former bus driver, who was in tears. He has a “room full of candy,” Abigail said, mostly Skittles, his favorite.

An autographed football from Kansas City Chiefs quarterback Patrick Mahomes arrived on his birthday. It made him cry, his father said, which happens pretty often.

“There are good and bad days, days that are more normal and easier, and then there are days where the family has to be a little bit more aware and supportive,” Abigail said in Spanish. “He’s always been outgoing and talkative like his mom, but that has changed since the parade.”

Fourth of July a weeklong trigger

The Fourth of July was particularly harrowing for many of the young survivors and their families. Should they buy fireworks? Will they want to celebrate? And why do all the firecrackers going off in the neighborhood sound like gunshots?

Fourteen-year-old Gabriella needed help from her stepfather, Jason Barton, to light her fireworks this year, something she is ordinarily enthusiastic about doing herself. At the parade, like many people, the Barton family initially mistook the sound of gunfire for fireworks.

And Erika Nelson, a single mom in Belton, Missouri, feared even bringing up the holiday with Mireya, who has always loved Independence Day. Eventually Mireya said she didn’t want any big fireworks this year and wanted only her mom to set theirs off.

“Just any little trigger — I mean, it could be a light crackle — and she just clenched,” Erika Nelson said.

Patty Davis, a program manager for trauma-informed care at Children’s Mercy hospital in Kansas City, said even her clients who were at the parade but were not injured still flinch at the sounds of sirens or other loud noises. It’s a powerful response to gun violence, she said.

“So not just an accidental trauma,” she said, “but a trauma that was perpetrated for violent purposes, which can cause an increased level of anxiety for persons around that to wonder if it’s going to happen again. And how safe are they?”

Reliving getting shot

Random sounds, bright lights, and crowds can catch the kids and their parents off guard. In June, Mireya Nelson was waiting for her older sister after a dance recital, hoping to see a boy she knew give a flower to a girl everyone said he had a crush on. Her mom wanted to go, but Mireya shushed her.

“Then all of a sudden, there was a loud boom,” Erika said. “She dropped low to the ground. And then she jumped back up. She goes, ‘Oh my God, I was getting shot again!’”

Mireya said it so loudly people were staring, so it was Erika’s turn to shush her and try to soothe her.

“I was like, ‘Mireya, it’s OK. You’re all right. They dropped a table. They’re just moving stuff out. It was an accident,’” Erika said.

It took a few minutes for the shock to wear off and Mireya later giggled about it, but Erika is always on watch.

Her daughter’s early sadness — she watched movies for hours, crying throughout — has since changed to a cheekiness. Half a year later, Mireya will joke about the shooting, which tears her mother up. But maybe that is part of the healing process, Erika says.

Before the Fourth of July, Mireya went to Worlds of Fun, a large amusement park, and had a good time. She felt OK because there were security guards everywhere. She also enjoyed a visit to the local FBI office with a friend who was with her the day of the shooting. But when someone suggested a trip to the ballet, Mireya squashed it quickly — it’s near Union Station, the site of the shooting. She doesn’t want to go downtown anymore.

Erika said the doctor appointments and financial strains have been a lot to juggle and that her biggest frustration as a parent is that she’s not able to fix things for her daughter.

“They have to go their own way, their own process of healing. I can’t shake her, like, ‘Get back to yourself,’” Erika said. “It could take months, years. Who knows? It could be the rest of her life. But I hope that she can overcome a little bit of it.”

Goose bumps in the sweltering heat

James Lemons noticed a change in his 5-year-old daughter, Kensley, who was on his shoulders when he was shot at the parade. Before the shooting Kensley was outgoing and engaged, James said, but now she is withdrawn, like she has closed off her bubble and disconnected from people.

Large crowds and police officers remind Kensley of the parade. Both were present at a high school graduation the family attended this summer, prompting Kensley to ask repeatedly to leave. James took her to an empty football field, where, he said, she broke out in goose bumps and complained of being cold despite the sweltering heat.

Bedtime is a particular problem for the Lemons family. Kensley has been sleeping with her parents. Another child, 10-year-old Jaxson, has had bad dreams. One night, he dreamt that the shooter was coming near his dad and he tripped him, said Brandie Lemons, Jaxson’s stepmom.

Younger children like Kensley exposed to gun violence are more likely to develop post-traumatic stress disorder than older children, according to Ohio State’s Johnson-Motoyama.

Davis, of Children’s Mercy in Kansas City, said children whose brains are not fully developed can have a hard time sleeping and understanding that they are safe in their homes at night.

James got the family a new puppy — an American bulldog that already weighs 32 pounds — to help them feel protected.

“I looked up the pedigree,” he said, “They’re real protective. They’re real loving.”

Searching for an outlet to let off steam

Gabriella took up boxing after the shooting. Her mother, Bridget, said it restored some of her confidence and control that dimmed after the parade.

“I like beating people up — not in a mean way, I swear,” Gabriella said in April as she molded a mouthguard to her teeth before leaving for training.

She has since stopped boxing, however, so the money can instead go toward a trip to Puerto Rico with her Spanish class. They’re paying $153 a month for 21 months to cover the trip. Boxing classes were $60 a month.

Bridget thought boxing was a good outlet for leftover anger, but by the end of July Gabriella wasn’t sure if she still had the drive to fight back that way.

“The past is the past but we’re still gonna all, like, go through stuff. Does that make sense?” Gabriella asked.

“You’re mostly OK but you still have triggers. Is that what you mean?” her mother asked.

“Yeah,” she replied.

After the shooting, Mireya Nelson tried online classes, which didn’t work well. The first few days of summer school, Mireya had a panic attack every day in the car and her mother took her home.

Mireya wants to return to high school this fall, and Erika is wary.

“You know, if I do go back to school, there’s a chance at school of being shot, because most schools nowadays get shot up,” Erika recalled her daughter saying. “And I’m like, ‘Well, we can’t think like that. You never know what’s gonna happen.’”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

The virus, also referred to as bird flu or H5N1, has been found in wild bird and domestic poultry flocks within the United States for years. But the ongoing outbreak in dairy cattle has forced animal and human health experts to establish testing for a new community of agriculture workers and livestock (Spencer Platt/Getty Images).

WASHINGTON —  The U.S. Department of Agriculture plans to embark on a year-long study beginning next month that will test samples for evidence of highly pathogenic avian influenza from former dairy cattle moved into meat production.

Emilio Esteban, the under secretary for food safety at the USDA, told reporters on a call Tuesday the new testing program follows three studies undertaken during the spring and summer that all found beef in the nation’s food supply is safe to eat.

“However, we want to move forward with an additional step,” Esteban said. “And what this means is that when those carcasses are tested, they are held and are not going to go into commerce until we get the results back.”

The virus, also referred to as bird flu or H5N1, has been found in wild bird and domestic poultry flocks within the United States for years. But the ongoing outbreak in dairy cattle has forced animal and human health experts to establish testing for a new community of agriculture workers and livestock.

The news of additional testing for the country’s meat supply came alongside the results of a study from the U.S. Food and Drug Administration that reinforced the safety of pasteurized dairy products.

Steve Grube, chief medical officer for the FDA’s Center for Food Safety and Applied Nutrition, said that the most recent round of dairy product testing included 167 foods that were processed in 27 states in June and July.

“None of the product samples contained viable H5N1, reaffirming that pasteurization is effective,” he said. “The second survey was intended to address geographic and product gaps from the initial sampling of the commercial milk and dairy product supply that the FDA conducted during April and May.”

Testing milk in bulk tanks

Federal officials have also launched a voluntary program for farmers to test the milk in bulk tanks for H5N1, a step that’s intended to make it easier for them to move their cows between states without having to individually test each one.

Eric Deeble, deputy under secretary for marketing and regulatory programs at USDA, said the department’s Farm Service Agency has approved 23 of the 35 applications it has received so far to help ease the financial burden on dairy farmers who take their herds out of production after testing positive.

The program — known as Emergency Assistance for Livestock, Honey Bees, and Farm-raised Fish — has approved more than $1 million in payments.

The price paid to farmers is based on a formula that includes the price of milk from the preceding month as well as the number of dairy cattle that contract H5N1.

Deeble said on the call with reporters that of the approved applications, a dozen are from Colorado, which has seen a sharp increase in the number of positive H5N1 tests within its dairy industry.

Deeble argued the uptick is due to certain factors within the state and cautioned people against assuming that if testing was increased in other areas of the country, the number of positive H5N1 tests for dairy cattle would spike.

“I don’t think that it is accurate necessarily to extrapolate from the situation in Weld County, Colorado,” Deeble said. “Weld County and Colorado dairy in particular is rather unique in the degree to which the dairies are all closely associated with one another; both spatially and the way in which there is a lot of movement between the facilities.”

“It is a tightly integrated dairy community that’s isolated from much of the rest of the state, and there is a lot of connectivity between the premises in the way in which they use vehicles, support services, milk trucks,” Deeble added.

During the last 30 days, five states have had dairy cattle test positive for H5N1, including Colorado, Michigan, Minnesota, South Dakota and Texas.

Colorado holds a disproportionate number of cases with 26 of the dairy herds to test positive, while the other four states combined hold a total of six herds.

Other mammals diagnosed with H5N1 during the last six weeks are overwhelmingly in Colorado, which has found the virus in house mice, deer mice, domestic cats, a desert cottontail and a prairie vole.

Effect on cats

Public health officials said during the call Tuesday they are beginning to look more closely at when and why cats are being affected by the spread of H5N1.

Barn cats as well as those that hunt outside, coming into regular contact with wild birds that hold a reservoir of H5N1, have tested positive for the virus before.

But a report from the Colorado Veterinary Medical Association earlier this month noted that two of the six cats diagnosed with H5N1 in that state this year “were indoor only cats with no direct exposures to the virus.”

Public health officials on the call were unable to answer a question about how indoor-only cats would have come into contact with H5N1.

Experts on the call cautioned that as fall approaches, wild birds will begin migrating and dairy farmers will likely ship their cattle at higher rates, both of which could lead to an uptick in the number of positive cases of H5N1 being reported in dairy cattle as well as other animals.

Lia Chien contributed to this report. 

Attendees cheer during a Missourians for Constitutional Freedom rally after the campaign turned in more than 380,000 signatures for its initiative petition to enshrine abortion rights in Missouri’s constitution Friday morning (Annelise Hanshaw/Missouri Independent).

Abortion will be on Missouri’s statewide ballot in November.

An initiative petition to enshrine the right to abortion up until the point of fetal viability received final approval Tuesday, securing a place on the general election ballot. If the measure receives a majority of votes, Missouri could become the first state to overturn an abortion ban through a citizen-led measure.

The Missouri Secretary of State’s Office had until 5 p.m. to certify all ballot measures that received enough verified signatures to qualify. It certified the measures as sufficient hours before that deadline. Also certified to be on the November ballot were proposals to legalize sports wagering and raise the minimum wage. 

Leaders with Missourians for Constitutional Freedom, the coalition behind the ballot measure, gathered at a press conference Tuesday to encourage Missourians to get out to vote. The coalition is headed by Abortion Action Missouri, the ACLU of Missouri and the state’s Planned Parenthood affiliates. 

“Politicians have tied doctors’ hands and the stakes could not be higher,” said Mallory Schwarz, executive director of Abortion Action Missouri. “ … With a yes vote on amendment 3 this November, we are taking back what’s ours.”

In Missouri, the first state to ban abortion after the U.S. Supreme Court overturned the constitutional right to the procedure two years ago, abortion is expected to be a focal point of the general election campaign.

Missouri is among 18 states with an abortion ban, and among several states working to put abortion on the ballot. In each state that put the issue on the ballot, citizens ultimately choose to protect the procedure.

“The measure takes away the right from every person who loses a child or a loved one because of negligence during pregnancy, labor or delivery the freedom to sue for malpractice and obtain compensation,” Stephanie Bell, a spokeswoman with Missouri Stands with Women, said in a statement Tuesday.

Tori Schafer, director for policy and campaigns for the ACLU of Missouri, responded to the comment, saying the statement is “fully false” and that the amendment doesn’t impact malpractice laws already in place.

What would the amendment do?

Abortion is illegal in Missouri, with limited exceptions only in cases of medical emergencies. There are no exceptions for survivors of rape or incest.

If the amendment receives more than 50% of votes in approval, the measure would legalize abortion up until the point of fetal viability, an undefined period of time generally seen as the point in which the fetus could survive outside the womb on its own, generally around 24 weeks, according to the American College of Obstetricians and Gynecologists. 

Such an amendment would return Missouri to the standard of the 1973 Roe v. Wade decision, which also legalized abortion up to the point of fetal viability. Missouri’s amendment also includes exceptions after viability “to protect the life or physical or mental health of the pregnant person.”

Missouri’s amendment also states that women and those performing or assisting in abortions cannot be prosecuted. Under current Missouri law, doctors who perform abortions deemed unnecessary can be charged with a class B felony and face up to 15 years in prison. Their medical license can also be suspended or revoked.

Dr. Selina Sandoval, associate medical director for Planned Parenthood Great Plains Votes, said the right to make decisions about abortion is personal and she sees each day the barriers and hardships bans cause.

“In Kansas right now, we are serving mostly out-of-state patients, including Missourians, who’ve had to flee their home states in order to simply access abortion care,” Sandoval said Tuesday.

Missourians for Constitutional Freedom, the coalition leading the reproductive-rights campaigns, is headed by Abortion Action Missouri, the ACLU of Missouri and the state’s Planned Parenthood affiliates. 

A decade ago, when abortion was still legal with fewer limitations, more than 5,000 abortions were performed in the state, according to data from the Missouri Department of Health and Senior Services. But by 2020, that number dropped to 167 due to a series of “targeted regulation of abortion providers” laws passed, including a mandatory 72-hour waiting period between the initial appointment and a surgical abortion and mandatory pelvic exams for medication abortions.

2 years after Missouri banned abortion, navigating access still involves fear, confusion

Since the Supreme Court decision in June 2022 through March 2024, there were 64 abortions performed in Missouri under the state’s emergency exemption, according to data from the Missouri Department of Health and Senior Services. 

A recent study by the Guttmacher Institute, a reproductive rights research group, showed that in 2023 alone, 8,710 Missourians traveled to Illinois and 2,860 Missourians went to Kansas for the procedure, which remains legal in both states. 

Despite the relative proximity to clinics in the Illinois suburbs of St. Louis and the Kansas suburbs of Kansas City, abortion access for Missourians has remained precarious at best.

Missourians hoping for abortions have increasingly found themselves competing for limited resources — including abortion funds and clinic appointment openings — especially as more southern states have outlawed the procedure, making Illinois and Kansas critical access points for women in states like Florida, Oklahoma and Texas. 

This has led many Missourians to increasingly rely on self-managed medication abortions. Rather than traveling across state lines, it’s estimated that thousands of Missourians received Mifepristone and Misoprostol to end their pregnancies at home in the past two years according to JAMA, the American Medical Association’s journal.

On Tuesday, members of Missourians for Constitutional Freedom continued to return to their continued fears for women’s health care in Missouri if a ban remains in place. Missouri already has stark maternal health care deserts, high maternal mortality rates, and recently saw a decrease in applicants to OB-GYN residency programs.

Schafer, with the ACLU, said the coalition plans to start rebuilding access to abortion on day one, if the measure passes.

“We know that after passage, constitutional amendments take 30 days to go into effect in the state of Missouri,” she said. “And we are hopeful that clinics will be open and our teams will be working toward that as our goal.”

Schwarz said they’ve been in contact with abortion providers about coming back to Missouri.

“After we win this in November, the impact will be regional and across the country,” she said. “And and from abortion providers that we are in close regular relationship and contact with, people are thinking all the time about where the next clinic can be, where the next opportunity is for them to grow and be able to support more and more patients.”

Wide support despite initial delays

The initial attempt to place abortion on the ballot began in March 2023. 

Legal fights with Republican state officials over the ballot language and internal disagreements on whether to include a viability ban stalled signature gathering attempts until January. 

As a result, the coalition had just 90 days to fundraise and collect signatures across the state.  

Meanwhile, Republican lawmakers were prioritizing an attempt to raise the threshold for approving citizen-led ballot measures. After a series of Senate filibusters, including one that broke records at 41 hours, the legislation failed on the final day of session. 

Missouri House Speaker Dean Plocher on the day of adjournment said that if abortion made it to the ballot and then passed in November under the current initiative petition guidelines, “the burden of abortion falls squarely on the Senate and its leadership.”

Despite these obstacles, the initiative petition garnered wide support across the state. 

As of July, the campaign raised nearly $7.3 million in donations, according to filings with the Missouri Ethics Commission.

Missourians for Constitutional Freedom turned in 380,000 signatures by their May deadline, including from each of Missouri’s 114 counties. To qualify for the ballot, they had to get signatures from 8% of registered voters in six of Missouri’s eight congressional districts, which equates to about 171,000 signatures.  

As of mid-July, the campaign had turned in more than enough valid signatures to land on the ballot, according to preliminary records from Missouri election authorities.

Once all verified signatures were turned in by election authorities in late July, the secretary of state’s office had two weeks to determine whether there were any final issues, like duplicate pages or missing affidavits signed by circulators. 

On Tuesday, the secretary of state’s office also certified ballot measures hoping to raise the state’s minimum wage and mandate paid sick leave and legalize sports wagering. A third proposal to authorize construction of a new casino near Lake of the Ozarks fell short of the needed signatures.  

This story was updated at 2:30 p.m. to include reactions from those supportive of and opposed to the amendment.

A repurposed 100-year-old barn is the centerpiece of the property at Guardian Hills Veterans Healing Center near Kirksville. “The Welcome Center is where it all starts,” said Jo Slawski, vice president and co-founder. The barn offers a space for reflection, dining and community as the curriculum of the week progresses (Zoe Homan/Columbia Missourian).

Navy veteran Jennifer Badger enlisted in 2001, was deployed to the Persian Gulf in 2002 and came home with post-traumatic stress.

After years battling addiction and homelessness, she found a refuge at the recently opened Guardian Hills Veterans Healing Center north of Columbia.

She calls it “a different type of healing” where veterans can spend a week in a peaceful setting recovering from the physical and psychological damage of combat.

“Being in nature with the horses and with people who genuinely care about me offered an experience like no other,” Badger said. “I can’t speak highly enough about Guardian Hills.”

The retreat opened in May on 750 acres near Kirksville for those suffering post-traumatic stress and moral injury — a complex condition caused by exposure to events that contradict deep moral beliefs and can result in guilt, shame, disgust and anger.

Veterans stay in a three- to four-bedroom cabin on the property and spend their time in self-reflection and therapy surrounded by horses, hiking trails and fishing spots.

The center also includes a multipurpose area, a self-expression activity building and a renovated 100-year-old barn, the centerpiece of the property, which serves as a social and dining center.

Since May, the staff has been running pilot programs to prepare for a full-on program launch next year. There are two remaining pilot sessions this year, scheduled for Sept. 15-21 and Oct. 20-26. Each session accommodates six to eight veterans, in addition to staff and volunteers.

The origins

The nonprofit organization that runs Guardian Hills was founded by Columbia surgeon Daniel Slawski and his wife, Jo, in the aftermath of 9/11.

Slawski, a veteran of the U.S. Air Force Medical Corps, was a practicing orthopedic surgeon and sports medicine specialist at the University of Nebraska when he began to see young patients traumatized by war in the Middle East.

“Many of them went into the military for an education. When 9/11 came around, their world turned upside down,” Slawski said. “Suddenly now they were being called into active duty not just once, not just twice, but sometimes three and four deployments overseas.”

“I was seeing kids come back changed pretty remarkably, and (seeing) some of my patients not come back, or in body bags, which affected me,” he said.

According to the U.S. Department of Veterans Affairs, nearly three in 10 veterans of the Global War on Terrorism will experience post-traumatic stress.

Slawski’s friend and founding board member Christopher Lozano had a similar experience working with young Marines.

“We got together and said, ‘What can we do to really make a difference?’” Slawski said. “What can we do to make an impact that’s not just a ‘thank you for your service’?”

The Slawskis donated land to build the center, and construction began in 2022. Since 2020, the Veterans United Foundation has provided Guardian Hills with over $1.5 million to continue its mission.

That and other donations have allowed Guardian Hills to offer the retreat to veterans for free.

The treatment

The program is based on the concept of post-traumatic growth, or PTG, introduced by psychologists Richard Tedeschi and Lawrence Calhoun in the 1990s.

When researching the effects of trauma, they were looking to develop positive psychological transformation among those who had suffered this kind of stress. They had a theory that people could learn to process trauma in a way that spurs resilience to adverse challenges.

Tedeschi and Calhoun noticed that those who experienced the most post-traumatic growth reported positive responses in five areas: appreciation of life, personal strength, relationships, spiritual change and new possibilities.

“They began developing ways to incorporate that into treatment and non-traditional treatment — that’s where a lot of these retreat programs come from,” Slawski said.

Both national and regional experts were consulted to develop the Guardian Hills curriculum, which incorporates “immersive educational and therapeutic experiences” to promote post-traumatic growth.

During their stay, veterans discover their inner strengths while working through a traumatic past. The retreat’s nature-based approach helps them focus wholly on healing without outside stressors.

They can build connections in the program — including with mentors who have also experienced trauma and growth — that foster a sense of community, all important aspects of recovery.

“These shorter-term programs are very intensive and start to peel the layers off, have people understand what they’re feeling and why they’re feeling it and give them coping and thriving mechanisms,” Slawski said.

All of the activities hold valuable lessons for veterans, Jo Slawski said. Skills are developed in stages to build self-awareness and provide the tools to regulate their emotions and behaviors.

“For example, with archery, if you keep your eye right on the tip of the arrow, you’re going to miss the target,” she explained. “You have to keep your eye on the target in order to get where you want to go.

“After that it’s, ‘Can you trust someone else to guide you? Let’s put a blindfold on.’ So, it’s can you rely on someone else because trust is one of the things destroyed,” she said.

After each weeklong session, the program will determine the levels of care and support veterans are going to need long term.

“Nobody is cured in a week,” Daniel Slawski said.

The future

Guardian Hills is now collaborating with MU’s statistics department to develop pre- and post-assessment surveys. The center is also working with students from MU and Truman State University who are interested in gaining experience both at the site and with research projects.

Allison Starke, an MU occupational therapy doctoral student, has been working on a research project to compile a database of state-based social and welfare resources for Guardian Hill’s website.

At Guardian Hills, Starke said she was able to observe how veterans found ways to share their experiences.

“When you get people moving with their hands, their minds open up in a way that they don’t really realize is happening, but then they can talk through things easier because they’re not sitting there just staring at someone talking,” Starke said.

“That was really interesting to see, the things that I had learned about in the past couple years actually come to life.”

In the future, the center wants to offer sessions that include family members and first responders, as well as programs tailored to those who experienced sexual trauma in the military.

During her stay at Guardian Hills, Badger said she learned things about herself she hadn’t discovered elsewhere.

“The archery, I would say, probably had the biggest impact on me,” she said. “Because it was the first time I realized that I didn’t have to try to impress anyone, that everyone was there to help and to be there, you know, to heal,” she said.

“I realized that it was OK to just be in the moment. It was OK to just be myself.”

Badger currently helps others who have gone through similar experiences, and she plans to mentor the veterans at Guardian Hills.

“When you wake up in the morning and you’ve got something to look forward to, it’s amazing,” she said. “I’m happy to be alive, and it’s people like Dan and Jo and programs like Guardian Hills that bring that out of me.”

This story originally appeared in the Columbia Missourian. It can be republished in print or online. 

The use of telehealth for abortion care has continued to grow in the U.S., according to the latest #WeCount report, particularly since five states passed laws legally shielding providers who work with patients living in states with bans (Warodom Changyencham/Getty Images).

Both the overall number of abortions and the use of telehealth abortion care continue to increase in the United States, according to the latest #WeCount report.

Telehealth made up 20% of all abortion care in the first three months of 2024, and the monthly total of abortions exceeded 100,000 for the first time since the group began tracking abortion data in 2022.

#WeCount is a collaborative group of researchers who collect national abortion data from clinics every month and is a project of the Society of Family Planning, a membership organization focused on abortion and contraception science. Alison Norris, co-chair of the group, said the data captures about 80% of abortion clinics nationwide. Using that data, the group makes estimates to account for clinics that do not provide reports.

From January to March 2024, there were about 19,700 telehealth abortions per month, according to the report, released Wednesday. The states with the biggest jumps in the average number of abortions per month compared with the first three months of 2023 include New York, California, Virginia, Kansas and Pennsylvania. Kansas saw 59% more telehealth abortions and 29% more in-person abortions each month.

Norris said the use of telehealth has continued to grow, particularly now that five states — New York, Massachusetts, Washington, Vermont and Colorado — specifically shield those who provide telehealth abortions from legal ramifications if they work with patients from states with abortion restrictions. Maine will become the sixth state when its shield law takes effect on Friday. Fourteen states in the U.S. have a near-total ban on abortion.

“There was already a move toward telehealth (during the COVID pandemic), but I think it was accelerated by the need,” Norris said.

Telehealth abortions provided by clinicians in states with shield laws averaged 9,200 per month from January to March 2024, according to the report. That’s an increase of about 1,200 per month from the last report that showed data from October to December 2023.

In the nine months from July 2023 to March 2024, over 65,000 people in states with near-total or six-week bans and states with telehealth restrictions have accessed medication abortion provided under shield laws.

But the vast majority of abortions still take place in person, Norris said, in part because medication abortion can only be prescribed via telehealth through 10 weeks’ gestation, and because some people just prefer to be seen in person.

The overall number of abortions per month has grown as well, with a high of 102,350 in January. The average over the first three months of 2024 was 98,990 — the highest monthly number during the last quarter of 2023 was 91,470.

Norris said the data shows the number of abortions began to rise nationally in 2017, and while it’s hard to pinpoint the cause, there are new factors that could be contributing. Some people who needed an abortion before the Dobbs decision in 2022 could get them once states passed legislation to remove barriers. And for those who faced financial issues obtaining an abortion, she said, there is more awareness of abortion funds and other sources of support.

“There’s a lot more information in the ecosystem, there’s better resources on the internet, and there’s potentially been a destigmatization of abortion, given how much it’s in the media and being talked about by politicians,” Norris said.

Although she views it as a positive that many people who live in states with near-total bans or six-week bans are able to access abortion via telehealth, she said it’s still an unfair situation.

“Those bans and those restrictions are not evidence-based in terms of public health science,” Norris said, “and the fact that thousands and thousands of people don’t have access to ordinary and safe health care that’s time-sensitive just because of the state where they live, it is an injustice that I hope people keep their eyes on.”

The Employee Retirement Income Security Act, or ERISA, was signed into law in 1974. It is meant to protect participants in employer-sponsored retirement and health plans by setting uniform standards for how the plans operate (Mint Images/Getty Images).

Oliver Lackey opened a pharmacy in his hometown of Fairview, Oklahoma, so he could “provide the best patient care.” He set up shop a decade ago in the local grocery store with “zero prescriptions.” Before long, business took off — yet he was still struggling.

“I was getting more patients and was filling more prescriptions,” Lackey told Stateline. “But as I grew in revenues, my reimbursement from the insurance companies and PBMs every year was getting worse.”

PBMs are pharmacy benefit managers, the intermediaries in the drug supply chain that manage prescription drugs for health plans. PBMs determine which drugs are available under a person’s insurance plan, set copayments and decide how much pharmacies must pay to acquire drugs.

PBMs argue that they use their bargaining power to negotiate lower drug prices for consumers and pharmacists. But critics say PBMs, some of which are owned by the largest health care corporations in the nation, engage in anticompetitive practices that lead to higher prices and drive independent pharmacies like Lackey’s out of business.

In recent years, all 50 states have enacted laws designed to lower prescription drug costs by curbing the power of PBMs, according to the National Academy for State Health Policy, a nonpartisan research group. But thanks to a 50-year-old federal law called the Employee Retirement Income Security Act, better known as ERISA, almost none of those measures applies to the 65% of Americans who work for large employers that cover their workers through so-called self-funded health care plans.

That could change if the U.S. Supreme Court upholds a PBM law enacted by Lackey’s home state of Oklahoma.

What is ERISA?

The Employee Retirement Income Security Act, or ERISA, was signed into law in 1974. It is meant to protect participants in employer-sponsored retirement and health plans by setting uniform standards for how the plans operate.

Five years ago, Oklahoma tried to rein in PBMs by approving a measure barring them from forcing pharmacies to pay certain fees or requiring patients to use PBM-owned or -affiliated pharmacies. The law also prohibited PBMs from giving more generous reimbursements to their own pharmacies or arbitrarily booting pharmacies from their preferred networks.

It was “the most aggressive, broadest PBM enforcement legislation in the country,” Oklahoma Insurance Commissioner Glen Mulready, a Republican, told Stateline. “And it was immediately challenged.”

The Pharmaceutical Care Management Association, a trade association representing PBMs, sued to invalidate the law. In August of last year, the 10th U.S. Circuit Court of Appeals ruled that ERISA, the federal law, prevented Oklahoma from applying much of its law to self-funded health care plans.

Greg Lopes, the trade group’s vice president of public affairs, said the Oklahoma law “would raise costs for health plans and consumers in the state.”

“Oklahoma’s law would devastate employer, union, and Medicare plan sponsors as well as hundreds of thousands of their beneficiaries, who would experience higher costs and reduced benefits,” Lopes said in an email.

But in May, the state pushed back: Oklahoma appealed to the U.S. Supreme Court to reverse the decision. In June, 32 state attorneys general and five pharmacist trade groups joined the lawsuit.

The Supreme Court hasn’t decided whether to take the case. If the high court eventually rules in favor of Oklahoma, legal experts say, it could establish an important precedent by allowing states to regulate the health plans that provide coverage to the majority of Americans, instead of being limited to regulating individual and group health plans and Medicaid programs.

But if the high court declines to hear the case or rules against Oklahoma, states will continue to have a hard time applying any state regulations to self-funded plans.

Whatever the outcome, it will come too late for Oliver Lackey. He was in business for six years but had to shutter his pharmacy in 2020, he said, because PBMs weren’t paying him enough for the drugs he was selling. He now works as the pharmacy director for the nonprofit Great Salt Plains Health Center, which serves patients in five Oklahoma locations.

“I had lots of patients who, when I announced that I was closing, came in crying,” he said. “It was a really tough time to go through that, because you’re essentially telling your family or your patients that you can’t afford to take care of them anymore.”

Origins of the law

The goal of ERISA, which President Gerald Ford signed into law in 1974, is to protect participants in employer-sponsored retirement and health plans by setting uniform standards for how the plans operate. The rules are designed to ensure that plan administrators run them in the interest of participants and beneficiaries, solely to provide benefits and cover expenses.

Congress approved ERISA in response to high-profile cases of underfunding and fraud in pension plans, said Elizabeth McCuskey, a professor of health law policy and management at the Boston University School of Public Health and School of Law.

“They made a lot of protections for employees, to make sure that the benefits promised to them by their employers were not being fraudulently reduced or squandered,” McCuskey said.

Under ERISA, large employers with thousands of employees in multiple states must abide by a single set of federal standards in their retirement and health benefits, rather than having to follow many different sets of state rules.

“Companies want to offer benefits, and they want to offer very good health plans for their employees,” said James Gelfand, president of the ERISA Industry Committee, a trade group representing large employers covered by the law. “However, it would not be possible to do that if they had to follow different rules in every state, every city or every municipality.”

Having to follow state-specific regulations — such as the ones in the Oklahoma law — likely would make it more expensive for large employers to provide health care coverage to their employees, Gelfand said. In response, he suggested, employers might stop offering certain benefits.

“We’ve also said to states, you know, if you pass a law that violates federal law, we will consider legal action, because our companies are not going to be able to offer benefits if they have to have a different plan in California and Texas and Maryland and Massachusetts,” he said.

At the time ERISA was approved, McCuskey explained, the main concern was pensions, not health care plans. “But it has this tradeoff,” she added, because “the thing that states want and need to regulate over the past 50 years has been their health care markets.”

Legal confusion

ERISA can be triggered fairly easily, so states must be careful when they try to regulate their health care markets, according to Joanne Roskey, an attorney at Miller & Chevalier, where she specializes in ERISA cases. As a result, their legislative efforts typically don’t apply to the nearly two-thirds of people enrolled in self-funded plans.

In 2020, the U.S. Supreme Court opened the door to at least some state regulation of PBMs in self-funded plans when it upheld a more limited Arkansas law. But the constant threat of ERISA-related lawsuits makes it challenging for legislators to do more to curb prescription drug costs, an issue that ranks high on voters’ lists of concerns, experts said.

“It’s so broad, and it’s so muddled, and there’s billions of dollars at stake,” Boston University’s McCuskey said.

McCuskey and other legal experts say a ruling on the Oklahoma case could clear the way for more action. Mulready, the state’s insurance commissioner, hopes they are right.

“We just need clarity on the issue,” he said. “That’s what’s needed by lots of folks across the country as they’re watching this or have watched this play out.”

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

People with symptoms of Long COVID attend a Senate Committee on Health, Education, Labor and Pensions hearing on Long COVID in January. A group of senators is now urging the Social Security Administration to grant greater access to disability payments for people with Long COVID symptoms (Drew Angerer/Getty Images).

Several U.S. senators have called on the Social Security Administration to take steps to make it easier for people with Long COVID to access disability benefits, actions that disability rights advocates and patients say are desperately needed.

Sens. Tim Kaine , Ed Markey, Tammy Duckworth, Bernie Sanders, Tina Smith, Angus King, and Richard Blumenthal signed the letter released on Monday. They said the agency should make the process more transparent, track and publish data on Long COVID applications, and consider expanding the listing of impairments the SSA considers in applications for benefits.

“In some situations, these symptoms can be debilitating and prevent an individual from being able to work, take care of their family, manage their household, or participate in social activities,” the senators wrote to SSA Commissioner Martin O’Malley.

Long COVID is a chronic health condition, which often includes fatigue, brain fog, and shortness of breath, following a COVID-19 infection. About three in 10 American adults have had Long COVID at some point, according to KFF’s April analysis of Long COVID data. About 17 million people had it in March 2024. In 2021, the U.S. Department of Health and Human Services released guidance on Long COVID as a disability under the Americans with Disabilities Act.

Kaine has been outspoken about his own experience with Long COVID and Sanders introduced legislation this month to provide $1 billion in funding each year for 10 years to support Long COVID research by the National Institutes of Health.

Lisa McCorkell, co-founder of the Patient Led Research Collaborative, a group of Long COVID patients and patients with associated illnesses, told States Newsroom, that creating a ruling or listing would be a huge improvement.

“Having that specific guidance for how to document Long COVID, its related diagnoses, and its associated impairment wo in uld assist physicians who may not be as knowledgeable about Long COVID,” she said.

The SSA administers disability benefits through Social Security Disability Insurance and Supplemental Security Income programs. The former program requires past employment payment into Social Security. The latter one does not have those restrictions and is based on financial need but to receive benefits, applicants have to prove they qualify as having a disability. The average monthly disability benefit for Social Security Disability Insurance is $1,538.

Long COVID’s economic cost

Researchers and economists are still trying to understand the full impact of COVID-19 infections and Long COVID on the workforce. A 2023 study estimated that COVID-19 brought down the labor force by 500,000 people and that the average loss of labor is equivalent to $9,000 in earnings. More than 25% of people with Long COVID said their condition had an impact on their employment or work hours, according to a 2022 Minneapolis Fed paper.

Long COVID is not going to go away, particularly as government protections on the federal, state, and local level to reduce the spread of COVID are “severely lacking,” said Marissa Ditkowsky, who serves as the disability economic justice counsel at the National Partnership for Women & Families, an organization focused on health, economic justice, and reproductive rights for women and families.

“While COVID continues to be a reality, we know that COVID disproportionately impacts women, disabled folks, and people of color, and the folks who are most impacted already have issues with access to appropriate health care, access to employment, and access to equitable wages,” said Ditkowsky, who has Long COVID. “A lot of folks might be working in low-wage jobs where they’re in the service industry and constantly out there and more likely to contract COVID. It starts not just with the programs for how to deal with folks with Long COVID, but how to prevent people from getting Long COVID.”

In the meantime, she said people with Long COVID, as well as other people with disabilities, would benefit from the changes senators are advocating, such as restoring the treating physician rule, which was repealed in 2017. The rule allowed the agency to give greater weight to medical evidence from a physician who treated a patient for years compared to, say, a doctor who examines a patient once.

“Giving your own doctor the weight [they] deserve is huge,” Ditkowsky said.

Mia Ives-Rublee, senior director of the disability justice initiative at the Center for American Progress, a liberal think tank, said there is an opportunity for the Biden administration or the next administration to revamp how the agency administers disability benefits.

She said that given the aging population, there is more reason than ever for the agency to make significant improvements to the application process. Advocates for people with disabilities say it’s also imperative to boost funding for the agency.

“Not only are we seeing an increase in disability in younger folks, but we’re also looking at the big boomer generation getting older … We’re going to see a huge pressure on the [SSA] and we need to see real changes and funding and think of ways to manage the wide variety of experiences that people have in order to deal with differences in applying for these benefits,” she said.

In vitro fertilization process close up (Getty Images).

When Missourians head to the polls in November, they may get to vote on whether to overturn their state’s near-total abortion ban and legalize abortions up to the point of fetal viability.

But one lawmaker says the results of that vote may not matter if his colleagues approve his bill declaring that fetuses are people.

Missouri state Rep. Brian Seitz, a Republican, plans to reintroduce a bill in January that would grant “unborn children” the same rights as newborns, building on a similar Missouri law that has been on the books since the 1980s.

Seitz said the bill would provide protections for embryos and fetuses “regardless of that vote in November.”

Absolute abortion bans remain unpopular, even in conservative-led states and among Republican women. So during this legislative session, many GOP state lawmakers pivoted to protecting the rights of fertilized eggs, embryos and fetuses. And when the national Republican Party released its official platform in July, it made no mention of a federal abortion ban. Instead, the GOP affirmed states’ prerogative to pass laws protecting life under the Constitution’s 14th Amendment, which has been used in legal arguments to support fetal personhood.

Fetal personhood, a longtime cornerstone of the anti-abortion movement, is the idea that a fetus, embryo or fertilized egg has the same legal rights as a person who has been born. If the law considers fetuses to be people, the thinking goes, then abortion would legally be considered murder.

Can a fetus be an employee? States are testing the boundaries of personhood after ‘Dobbs’

At least 19 states — either through state law, criminal statutes or case law — have declared that fetuses at some stage of pregnancy are people, according to a 2023 report from Pregnancy Justice, a nonprofit that conducts research and advocates for the rights of pregnant people, including the right to abortion.

Missouri is one of several Republican-led states where lawmakers have taken a renewed interest in fetal personhood legislation in the two years since the U.S. Supreme Court’s Dobbs decision overturned Roe v. Wade and dismantled the federal constitutional right to abortion.

“If you elevate a fetus to the status of a person and grant it citizenship rights equal to that of a pregnant person, then now you have a clash of rights,” said Rebecca Kluchin, a history professor at California State University, Sacramento, who is writing a book on the history of efforts to establish fetal personhood in the United States.

Kluchin said one goal of the recent fetal personhood bills is to get a case before the U.S. Supreme Court. The Dobbs decision, and the conservative bent of the current court, have created an environment where lawmakers are saying, “Let’s try it,” she said. “If one of them gets it right, then others can pass identical laws.”

Seitz thinks his bill could fulfill that purpose.

“If it does get to the Supreme Court, due to the makeup of the court right now, I think they would see this commonsense legislation is, in fact, truth,” he said.

Critics, meanwhile, warn of legal chaos. The possible implications of fetal personhood bills extend far beyond abortion — to fertility treatments, birth control and even child tax credits. In states that have enacted such laws, pregnant women have faced criminal charges for actions that might harm their pregnancies.

“When a pregnant person’s rights conflict with fetal rights,” Kluchin said, “fetal rights tend to trump them.”

IVF’s chilling effect

Seitz’s bill didn’t make it out of committee before Missouri’s legislative session ended in May.

He attributed that failure to the GOP’s reluctance to push an anti-abortion bill in an election year, a concern that might have been justified: Missouri abortion rights supporters gathered more than double the number of signatures needed to get their constitutional amendment on the ballot. As of press time, the ballot petition signatures were still being reviewed by local and state officials.

But Seitz said the bill will be the first he introduces when the legislature returns in January. With election season behind them, he said, “I think it will be very easy for my Republican colleagues to come on board and support this.”

Conservative lawmakers in Alaska, Illinois, South Carolina and West Virginia introduced similar fetal personhood bills in their most recent legislative sessions, though none made it out of committee.

Then in February, the Alabama Supreme Court ruled that embryos created through in vitro fertilization are children under state law, and that people can be held liable for destroying them. The court cited Alabama’s constitutional amendment, passed by voters in 2018, that confers personhood on fetuses and affirms the state’s responsibility to protect “the rights of unborn children.”

The court’s decision generated a national uproar, ignited bipartisan ire and halted fertility treatments statewide until Alabama’s Republican supermajority legislature hastily passed a law protecting fertility service providers.

The backlash underscored how many lawmakers hadn’t fully considered the far-reaching implications and legal bedlam that can be created by fetal personhood laws.

And it had a chilling effect on fetal personhood bills.

In February, a Florida Republican state senator sidelined her bill that would have covered fetuses under wrongful death lawsuits after some lawmakers worried it would hurt IVF providers.

In March, the Iowa House passed a bill to criminalize “the death of an unborn person,” but Republicans in the Senate declined to take up the bill over concerns it could criminalize IVF.

Similarly, the Kentucky House refused to hear a bill that the Senate passed that would have granted the right to retroactively collect child support for costs incurred during pregnancy.

Through the back door

Last year, Arizona Republican state Rep. Matt Gress introduced five pregnancy-related bills that he said were inspired by his experience growing up in a family headed by a single mother.

“I’m the youngest of four and raised by a single mom in a single-wide trailer house in rural Oklahoma. We grew up very poor,” Gress said in an interview with Stateline. “These bills, to me, represented a policy approach that helps women and families.”

One of the bills would have allowed families to retroactively claim child tax credits in the year before a baby is born; another would have allowed pregnant women to drive alone in a highway car pool lane, their fetus counting as a separate passenger.

Yet another bill would have allowed a woman, after having a baby, to collect child support backdated to the date of her positive pregnancy test.

Arizona’s Democratic state legislators accused Gress of taking a back-door approach to inserting fetal personhood language into state law. But Gress denies that codifying fetal personhood was his intent.

“That didn’t even cross my mind,” he said. “The way I read the bills, there were no rights being afforded to anybody besides women and families.”

Gress noted that he was the first Republican, and one of the few, who supported Democratic state legislators’ bid to repeal Arizona’s near-total abortion ban, which dated to 1864. The repeal effort eventually succeeded in early May.

Arizona’s legislature passed two of Gress’ pregnancy bills, but Democratic Gov. Katie Hobbs vetoed both. Gress said he doesn’t intend to reintroduce the bills unless a new governor is elected who might support them.

Republican and Democratic lawmakers in Alabama, Kansas, Kentucky, Mississippi and Missouri tried but failed to pass similar fetal child support laws this year. Georgia’s 2019 “heartbeat law,” which went into effect in 2022, grants child support benefits for fetuses.

Republican U.S. Rep. Mike Johnson of Louisiana, now the speaker of the House, introduced a similar bill in Congress in 2022, and was explicit about its purpose. In a statement, he called it a “first step” toward updating federal laws to reflect that “life begins at conception.”

Beyond abortion

Fetal personhood laws, like abortion bans, end up having broader effects on all pregnant people and pregnancy-related care, said Dr. Daniel Grossman, an OB-GYN and the director of Advancing New Standards in Reproductive Health, a research program at the University of California, San Francisco, which focuses on abortion and reproductive health.

Grossman points to cases in which pregnant patients experiencing obstetric emergencies had to be airlifted out of states with strict abortion bans, such as Idaho, because doctors were afraid of violating the law.

In states such as Florida, North Carolina and Texas, pregnant women who weren’t seeking abortions but who experienced possible miscarriages or other emergencies have been turned away from hospitals. Stories of pregnant women being turned away from emergency rooms spiked after Roe was overturned, a recent Associated Press investigation found.

Fetal personhood has implications for birth control, too.

Hormonal contraceptive methods such as IUDs and birth control pills typically work by preventing an egg from being fertilized, but there’s a small chance that some forms can also prevent a fertilized egg from being implanted in the uterus, said Grossman. So, if state law considers a fertilized egg a person, that could create a legal basis for banning any contraception that could possibly prevent implantation.

Grossman also worries about increased scrutiny these laws create for people who experience miscarriage or stillbirth.

“Before Dobbs, people were arrested and criminally prosecuted for allegedly trying to end a pregnancy on their own,” he said. “I’m already concerned that’s going to become more common, especially in places with fetal personhood laws.”

The laws also have resulted in women being criminally charged for actions that might harm their pregnancies, said Lourdes Rivera, president of Pregnancy Justice.

Rivera’s organization documented nearly 1,400 instances of pregnant women being charged, often for substance use, in the 16 years leading up to the June 2022 Dobbs decision. Most of the cases occurred in a handful of Southern states — including Alabama, South Carolina and Tennessee — that have expanded their definitions of child abuse to include fetuses, fertilized eggs and embryos.

Nearly 85% of pregnancy criminalization cases in the Pregnancy Justice report involved charges against a pregnant person who was legally indigent, and the laws were disproportionately applied to poor women and women of color, Rivera said.

“These laws are forcing pregnant people to give up their bodily autonomy, their health and well-being,” she said, “and to be surveilled and criminalized for actions that would not be criminal if they were done by people who were not pregnant.”

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

(Credit: Katarzyna Bialasiewicz/Getty Images)

Missouri in the last year has significantly reduced its backlog of overdue nursing home inspections, recent federal data shows, though it still stands out for how low nursing staff is at many facilities.

Around this time last year, a quarter of nursing homes hadn’t been inspected in at least two years. 

Now the number is closer to 3%, according to Centers for Medicare and Medicaid Services data.

The state’s surveyors “have investigated complaints at night, early morning, weekends and holidays,” said Lisa Cox, spokesperson for the Department of Health and Senior Services. “The decline in overdue complaints can be attributed to the hard work and dedication of our surveyors and inspectors.”

The department also hired certified part-time staff to help with the backlog, received additional money in this year’s budget to increase the nurse surveyor salaries and has contracted with private agencies to get additional staff, Cox said.

The backlog had mounted in part due to state staffing issues, plus an increase in complaints.

When the state resumed its standard inspections in January of 2021, after a COVID pause, there were over 4,000 pending complaint investigations and now there are 265.

Still, advocates are worried about oversight in Missouri’s nursing homes. 

The main issue that has come up for years is Missouri’s low level of nursing home staffing.

The most recent data, updated last month, shows residents receive 3.3 hours of daily care, on average. That’s below the federal standard of 3.48 daily hours that is going into effect over the next few years — and even that was a level advocates fought for being too low.

Missouri has consistently ranked among the worst states for nursing home staffing levels.

Staffing varies widely by facility in the state. Two dozen facilities offer less than 2 hours of daily nursing care per resident.

The for-profit Reliant Care owns several of the largest facilities in Missouri. Sixteen of the entities associated with Reliant Care offer less than 2 hours of daily individual nursing care, according to the latest data.

One, North Village Park, offers just 37 minutes per day of care, the federal data shows.

Marjorie Moore, executive director of VOYCE St. Louis, an advocacy group for long-term care residents, said Missouri’s nursing home staffing is one of the biggest challenges facing residents.

“A lot of people are going to be laying in bed all day uncared for because there’s short staffing in the facilities,” she said. 

She said they’ve recently been hearing about a lot of residents who don’t have nurses to come get them out of bed to attend activities.

Moore said the state’s ombudsman program, which is an oversight arm composed of staff and volunteers who advocate for long-term care residents, can help but needs more resources.

Moore’s organization operates the ombudsman program for St. Louis and Northeast Missouri regions.

“Those residents really rely on ombudsmen, both staff and volunteers, to speak up for them and to make sure that they’re getting the care that they need and that they deserve,” she said.

Ombudsmen make sure residents can go to the bathroom, take their medications and be fed on time, as well as enjoy activities.

Without the oversight that ombudsmen offer, she said, “it’s very easy for people to just kind of say, ‘Oh well, the call light was on for a long time, I just didn’t get to it.’”

For the second year in a row, Gov. Mike Parson vetoed the $2.5 million increase the legislature approved for the program, which would have added around 25 staff statewide, Moore said.

Parson wrote that “while this supports the important goal of helping seniors throughout the state, there is insufficient funding from the appropriated source to support this item.” 

Moore said she was aware of some issues with the source lawmakers assigned to draw funding from but was hopeful they’d be resolved by the end of session.

“We have a lot of challenges here in Missouri for nursing homes,” she said. “…It’s definitely a disappointment.”

Mylissa Farmer shares her story for a 2022 TV ad for Democratic Senate candidate Trudy Busch Valentine (screenshot).

Two years ago, Mylissa Farmer was denied an emergency abortion at hospitals in Missouri and Kansas while experiencing a miscarriage. 

On Tuesday, she filed a lawsuit against one of the hospitals — The University of Kansas Health System — accusing the hospital of sex discrimination and saying it violated a federal law meant to ensure doctors treat patients who come into the emergency room. 

A spokesperson with the health system did not immediately respond to a request for comment.

“While Ms. Farmer was clearly in the midst of a complicated and dangerous miscarriage — and there was no chance her fetus could survive — the care she needed was an abortion because fetal cardiac activity was still detectable,” states the lawsuit filed in Kansas federal court. “Ms. Farmer was entitled to this emergency abortion care under state and federal law.”

Farmer was living in southwest Missouri when she miscarried. Several weeks earlier, Missouri banned abortion in the wake of the U.S. Supreme Court overturning the constitutional right to the procedure. 

The day she went to an emergency room — cramping and bleeding at 18 weeks pregnant — Kansas voters were heading to the polls to vote in favor of keeping abortion legal in that state.

Farmer went to the emergency room at Freeman Health’s emergency department in Joplin at her OB-GYN’s urging. There, medical staff determined the pregnancy was no longer viable, but because the fetus had a heartbeat, and because Farmer’s condition wasn’t immediately life-threatening, she was turned away. 

Hospitals in Joplin, KCK cited for denying emergency abortion to Missouri woman

According to the lawsuit, doctors told Farmer that she was at risk of infection, severe blood loss, the loss of her uterus and death. But they would not help her because of Missouri’s abortion ban, which had only been in place for several weeks, outlawing all abortions with limited exceptions in cases of medical emergencies. 

Farmer then traveled three hours across the border to a hospital in Kansas, where abortion is limited after 22 weeks gestation. However, doctors at the University of Kansas Health System also refused to perform an abortion. Kansas law bans abortions at any facilities run by the University of Kansas Hospital Authority, with exemptions for the life and health of the mother.

“Ms. Farmer arrived at (the University of Kansas Health) heartbroken, in pain and terrified for her life,” the lawsuit reads.

The doctor who saw Farmer initially told her the hospital would induce labor so Farmer could then hold her daughter and say goodbye, according to the lawsuit. But the doctor later said her decision had been overridden by others at the hospital, and that she could no longer induce labor because it would be too “risky” in Kansas’ “heated” political environment to do so when the fetus still had a heartbeat.

Instead, according to the suit, the hospital refused to even perform routine checks such as taking her temperature and assessing her pain. She was turned away without so much as Tylenol or antibiotics to ward off potential infection despite Farmer being at high risk for infection and experiencing heavy bleeding, mental fog and acute pain. 

She returned to the Joplin hospital the next day, was kept overnight and then released without additional treatment.

Farmer eventually traveled several hours to Hope Clinic in Granite City, Illinois, for an abortion on Aug. 5. On the drive there, according to the suit, she was in excruciating pain, by then several days into her miscarriage and almost fully dilated.

Back home after the abortion, Farmer’s OB-GYN diagnosed her with an infection and prescribed her antibiotics.

The damage to Farmer’s health and wellbeing was long-term, the lawsuit argues. She was hospitalized several times after the miscarriage, and was unable to work for months. She eventually lost her home and moved out of Missouri.

What Farmer experienced at the Kansas hospital “compounded the trauma of her pregnancy loss and denied her the ability to mourn that loss on her own terms,” the suit reads.

Farmer, who has a history of polycystic ovary syndrome, had feared she and her husband would not be able to get pregnant prior to the summer of 2022, the lawsuit reads.

Her story caused national outrage as women and providers in states with abortion bans and restrictions navigated new and often vague laws. Under Missouri’s new ban, health care providers who perform abortions that weren’t deemed medical emergencies can be charged with a class B felony. If convicted, they would face up to 15 years in prison and their medical license could also be suspended or revoked.   

In a letter to the hospitals several months later, U.S. Secretary of Health and Human Services Xavier Becerra warned that both locations had to provide all necessary care required by federal law. A report by the Centers for Medicare and Medicaid Services found both hospitals had violated the Emergency Medical Treatment and Labor Act. 

This act, known as EMTALA, requires that hospitals treat patients with emergency conditions despite their ability to pay. 

“Although her doctors advised her that her condition could rapidly deteriorate, they also advised that they could not provide her with the care that would prevent infection, hemorrhage, and potentially death because, they said, the hospital policies prohibited treatment that could be considered an abortion,” Becerra wrote in May 2023. “This was a violation of the EMTALA protections that were designed to protect patients like her.”

The federal lawsuit comes in the wake of an Idaho EMTALA case recently argued before the U.S. Supreme Court. While awaiting the decision, thousands of doctors, including dozens across Missouri, asked the court to uphold EMTALA.  

Emergency care for pregnant women at stake in Supreme Court case, Missouri doctor warns

The nation’s highest court sent the case back down to the court of appeals. Earlier this year, several women with high-risk pregnancies were airlifted to other states in order for emergency physicians to avoid performing emergency abortions in a state with a ban on the procedure.

Unlike the Idaho case, which was brought by the government, Farmer’s is the first high profile EMTALA lawsuit brought after the fall of Roe by an individual denied an emergency abortion, said Kenna Titus, a legal fellow with the National Women’s Law Center, the organization representing Farmer.

“In the post-Dobbs world, we know that these protections that are provided by EMTALA for pregnant people are more important than they’ve ever been,” Titus said. “A clear decision in this case will make it clear for people across the country that are dealing with this that this is not a gray area. Federal law requires abortion care in emergency situations like this.”

As of Wednesday, no lawsuit had been filed in federal court against the Joplin hospital.

(Photo courtesy of Iowa State Dairy Association).

Federal health officials are encouraging farm workers who tend livestock and poultry to get vaccinated for seasonal influenza to help prevent a bird flu mutation that might spark a pandemic in people.

The U.S. Centers for Disease Control and Prevention said Tuesday it would devote up to $5 million to pay for the vaccinations, and that it will rely on states to implement the initiative.

There are 14 known human infections of highly pathogenic avian influenza that resulted from contact with infected dairy cattle and poultry in the United States, and all but one has happened in the past four months.

The virus has been circulated by wild birds for more than two years and has sporadically transmitted to domestic birds. A variation of the virus has been infecting U.S. dairy cattle since December, and four people who worked closely with infected cattle also became ill.

In recent weeks, nine people in Colorado who were tasked with culling infected poultry contracted the virus.

The CDC has maintained that the virus’ risk to humans is low — those who have been infected so far had minor symptoms of respiratory illness or pinkeye, or both.

It has not been shown to transmit between people, but the virus has the potential to rapidly gain that ability if it infects someone who also has a seasonal flu virus.

“Such dual infections, while rare, could potentially result in an exchange of genetic material between two different influenza viruses,” Dr. Nirav Shah, principal deputy director for the CDC, said in a call with reporters Tuesday.

Shah said that “reassortment” process could pose a “significant public health concern” if bird flu gains the ability to spread person-to-person the way seasonal flu does, potentially resulting in a virus that spreads easily and causes severe symptoms.

A new vaccination campaign

Shah said the CDC will devote up to $10 million for farm workers’ health related to avian flu. Half will be spent educating and training farm workers about how to avoid being infected.

The other half will pay for seasonal flu vaccines for an estimated 200,000 farm workers who tend livestock and poultry. The CDC hopes to vaccinate all of them but acknowledges that less than half of the general population typically gets a flu shot.

How the voluntary vaccination effort will proceed is unclear. State health officials are expected to implement them, most immediately in the 13 states that have confirmed infections among cows.

That includes Iowa, where 13 dairy herds have been infected. However, no new infections have been reported in the state in the past month.

A spokesperson for the Iowa Department of Health and Human Services — which presumably would coordinate with the CDC — did not immediately respond to a request to comment for this article.

The vaccine will not protect the workers from contracting bird flu, Shah said, nor will it guarantee they won’t be infected by seasonal flu. But he said it’s an important component of the public health response to the new virus’ threat.

“The risk here is a theoretical but important risk,” Shah said.

Colorado has most recent infections

The confirmations of new bird flu infections among cattle have waned significantly in most states, except for in Colorado. In the past 30 days, two-thirds of the nation’s 32 newly infected herds were in that state, according to U.S. Department of Agriculture data.

Some of that might be due to Colorado’s robust testing protocols, but it’s also “a quirk of history and geography,” said Eric Deeble, deputy under secretary for marketing and regulatory programs for the USDA.

The state has far fewer dairy farms than the leading milk-producing states, but most of them are concentrated in one county.

“They are all in very close proximity to one another, and so there is a lot of sharing of equipment, a lot of sharing of personnel and a lot of movement on and off farms to adjacent farms,” Deeble said.

The USDA has identified the movement of equipment and people between dairy farms as a primary vector for virus transmissions from herd to herd and from herd to flock.

The virus has been identified in 172 dairy herds in the United States this year. Fifty of them are in Colorado. In Texas, where the infections originated, the virus was confirmed in 22 herds, although there were many that went untested because they recovered before bird flu was identified as the culprit.

This story was originally published by the Iowa Capital Dispatch, a States Newsroom affiliate. 

Sen. Mike Moon, R-Ash Grove, speaks on the Senate floor about his bill on gender-affirming care on Feb. 27, 2023 (Annelise Hanshaw/Missouri Independent).

A circuit court judge ruled Monday that state Sen. Mike Moon is immune from questioning in a legal challenge of Missouri’s restrictions on gender-affirming care that he sponsored in 2023.

Wright County Circuit Court Judge Craig Carter, who is stepping into Cole County for the case, agreed with the Missouri Attorney General’s Office that Moon should not be questioned under oath in the case. However, he ruled against the attorney general by rejecting a request to push the trial until after the U.S. Supreme Court hears a similar case.

Attorneys with the ACLU sought to ask Moon, a Republican from Ash Grove, about his communications with lobbyists and advocacy groups in the creation of Missouri’s law. The ACLU is joined by law firms Bryan Cave Leighton Paisner and Lambda Legal seeking to stop the implementation of the law, which became effective nearly one year ago.

ACLU attorney Kristin Mulvey wrote in the plaintiff’s argument that Moon’s communications to advocacy groups, obtained by the ACLU via open records requests, show discriminatory intent in the law’s drafting process.

“Plaintiffs… should be able to examine communications the act’s sponsor had with third parties about the law as they are relevant to the reasons it was passed in Missouri and are likely to demonstrate that the real interests and motivations behind the passage of the act are not what the state claims them to be,” she argued.

The law, coined the SAFE Act, has placed restrictions on gender-affirming care for children, adults on Medicaid and incarcerated Missourians. The text “was apparently supplied by the interest group Family Policy Alliance,” Mulvey wrote.

Family Policy Alliance, based in Colorado Springs, uses religious doctrine to oppose gender-affirming care, gay marriage and abortion.

The attorney general’s office, in a motion filed by Assistant Attorney General Matthew Tkachuk, argued that Moon cannot be questioned because of “legislative privilege.”

He cites the Speech and Debate Clause in the U.S. Constitution, which says “for any speech or debate in either House, (senators and representatives) shall not be questioned in any other place.”

Mulvey argued the clause applies to Moon’s speech on the Senate floor but does not protect his communication with third parties. She emphasized voters amended  Missouri’s Constitution in 2018 clarifying that legislative records are open.

But Tkachuck said legislative intent is protected and, regardless, irrelevant to the law’s constitutionality.

Tkachuck said during Monday’s hearing that the subpoena of Moon was “unconstitutional, unprecedented and unhelpful.”

“The motivations of an individual legislator are not relevant to the constitutionality of a statute, which either meets constitutional muster on its merits or does not,” he wrote in the state’s argument.

Separately, the parties argued about the trial’s timeline. It is scheduled for a bench trial, meaning the judge rules on constitutionality, in late September.

Peter Donahue, assistant attorney general for special litigation, told Carter the witness list had been reduced to 35 people: 20 for plaintiffs and 15 for the state with “substantial discovery on both sides.”

Lawsuit seeks to block Missouri ban on transgender care for minors

The discovery process has been burdensome for both parties, with each asking Carter to force the disclosure of documents they deemed wrongfully withheld.

Donahue said he foresees litigation with the World Professional Association for Transgender Health, a third party the attorney general’s office is seeking information from for the case, to get documents.

Omar Gonzalez-Pagan, an attorney for the plaintiffs, said “nothing here in the discovery schedule compels the motion for a continuance.”

The attorney general’s office sought to delay until the U.S. Supreme Court rules on Tennessee’s gender-affirming-care ban. Gonzalez-Pagan said it would likely be a year — a long time for the patients who have been denied medical care under the law.

“It just flies in the face of everything this case is about to say that in a delay of a year, no harm is caused,” he said.

There are matters that the Supreme Court case will not touch on, like Missouri’s restrictions for Medicaid patients and incarcerated individuals, Gonzalez-Pagan told Carter.

Other courts are hearing challenges to their state bans, and just one has delayed trial, though it was at the request of the plaintiff, he said.

Gonzalez-Pagan cautioned that the plaintiffs may age-out of the statute if delays continue.

“The plaintiffs in this case deserve their day in court,” he said. “By asking for a continuance, the state is in essence denying it.”

Missouri’s attorney general is embroiled in a handful of lawsuits after he launched an investigation of gender-affirming care. He has asked for records from those who provided hormone-replacement therapy prior to the law’s enforcement and called for the State Division of Professional Registration to prod therapists who have referred minors for gender-affirming care.

Moon could not be immediately reached for comment.

Missouri continues to higher rates of maternal and infant mortality, breast and cervical cancer deaths and preterm births, according to a study from the Commonwealth Fund (Getty Images).

Missouri women have more limited access to health care and worse outcomes than any other state in the Midwest, a new study of the nation’s health care system found. 

Missouri ranks 40th out of 51 states plus the District of Columbia on the 2024 state scorecard on women’s health and reproductive care, published by the Commonwealth Fund, a private foundation focused on health care issues.

The study assessed and compared 32 pieces of information derived primarily from public data sources in 2022, which was after most of the major effects of COVID had been felt, but before most abortion bans had really started to impact data findings, the creators of the scorecard said.

Missouri continues to see maternal and infant mortality rates, breast and cervical cancer death rates, preterm births, congenital syphilis and depression leading up to or during pregnancy at rates that are higher than the national average. 

There are more women in Missouri between the ages of 18 and 44 reporting they hadn’t seen a doctor in the past year because of the cost than all but 10 other states. 

“One thing is absolutely clear,” Joe Betancourt, president of the Commonwealth Fund, told reporters when the study was published last week. “Women’s Health in the U.S. is in a very fragile state.”

Missouri ranked among the states with the lowest low-risk c-section rates, postpartum depression and up-to-date pneumonia vaccines for post-menopausal women. But it fared among the worst nationally for breast and cervical cancer deaths, up-to-date pap smears, and mental health among women ages 18 to 64.

It also ranked poorly when analyzing access to abortion clinics. Nearly every abortion became illegal in Missouri in 2022. A citizen-led ballot measure is hoping to enshrine abortion rights in the Missouri constitution. 

“We are seeing a deep and likely growing geographic divide in U.S. women’s ability to access vital health services and maintain their health,” said Sara Collins, a co-author on the Commonwealth Fund study. “Particularly among women of reproductive age.”

Ashley Kuykendall, director of service delivery for the Missouri Family Health Council Inc., a nonprofit working to strengthen health care access across the state, said one of the most stark findings of the report was the combination of lack of access to wraparound care paired with poor health outcomes.

But solutions exist, she said. 

One such solution: a women’s health omnibus bill that failed to pass in the statehouse this year despite widespread bipartisan support, that would have expanded birth control coverage, increased congenital syphilis testing and eased access to mammograms and STI testing.

“The state legislature has an incredible power and responsibility to support better care for people across the reproductive health spectrum,” Kuykendall said. “Especially, as this report highlights, for folks who are pregnant or postpartum.” 

Health and reproductive care outcomes

Missouri ranked 43 of 51 for this category, which includes maternal and infant mortality and physical and mental health issues. 

Some data was analyzed using the Centers for Disease Control and Prevention’s Pregnancy Risk Assessment Monitoring System.  Missouri is among 33 states who participate in this federal program. Of those states, Missouri had the highest percentage of women who recently gave birth and reported experiencing intimate partner violence before, during or after their pregnancy.

Missouri has some of the highest pregnancy-associated maternal mortality rates in the United States, which already ranks worst among countries of similar economies for high maternal deaths.

In Missouri between 2018 and 2020, women on Medicaid were 10 times more likely to die within a year of pregnancy than women on private insurance, according to a 2023 report from the state’s Pregnancy-Associated Mortality Review. Black mothers were three times more likely to die within a year of pregnancy than white mothers. 

Of the 210 pregnancy-related deaths over those three years in Missouri, the majority were deemed preventable.

Mental health conditions were the leading underlying cause of death, including due to suicide and substance use.

The latest study found Missouri had one of the highest percentages of women between the ages of 18 and 64 who reported poor mental health, landing 48 of 51. 

Coverage, access and affordability

Missouri ranked slightly better — 39 of 51 —  in this category, which includes insurance coverage and health care affordability and access. 

Of the 33 states that provided data around health insurance coverage, Missouri ranked third-worst for women uninsured the month before becoming pregnant, and sixth-worst for women who didn’t have health insurance during a recent pregnancy. 

This is despite Missouri legislators’ decision to expand postpartum Medicaid coverage from 60 days to a year in 2023. 

A better-funded, better-staffed and more accessible public health safety net is also critical, said Kuykendall. 

This summer, Gov. Mike Parson signed into law a bill ending Medicaid reimbursements to Planned Parenthood, including for patients who go to the clinic for preventive exams, family planning and STI testing. Those opposed to the bill warned such a law would strain the state’s already fragile public health safety net.

“The need for these services far outweighs the current capacity for the safety net to provide them,” Kuykendall said. “Any funding cuts to those providers not only limits patients’ ability to access care, but also puts further strain on the health care workforce and will undoubtedly worsen these outcomes.”

Recent surveying by the health care nonprofit found that wait times across the state’s overburdened safety net clinics averaged between five and seven weeks. These 68 clinics receive Title X funding and do not turn anyone away, regardless of their ability to pay.

The study found that approximately 5.6 million women across the country live in counties that are considered maternity care deserts.

In Missouri, 41% of counties are designated maternity care deserts, meaning there are no maternity care providers or birthing facilities. Missouri’s rate is higher than the national rate of 32%, according to a separate 2023 report from the March of Dimes. Across the state, 10% of women do not live within 30 minutes of a birthing hospital.

In the last decade, 19 hospitals across Missouri have closed, according to the Missouri Hospital Association.

“There is an issue of access that’s very real,” Kuykendall said.

The authors of the study were also deliberate in considering outcomes in states with abortion bans and restrictions. 

“There’s concern that abortion bans or limits will further reduce the number of providers offering maternity care owing to increased risk of legal action that provider’s face,” said David Radley, a senior scientist with the Commonwealth Fund. “Especially when states’ laws are ambiguous.”

A recent study showed states with abortion bans saw a significant decrease in the number of medical residents applying to be in their OB-GYN programs.

2 years after Missouri banned abortion, navigating access still involves fear, confusion

Missouri saw a 25% drop in applicants since 2022, the highest drop in the nation second only to Arizona.

“These inequities are long standing, no doubt, but recent policy choices and judicial decisions restricting access to reproductive care have and may continue to exacerbate them, Commonwealth Fund president Betancourt said of the study’s findings when related to states with abortion bans. 

“It also serves as a glaring reminder that where you live matters to your health and health care.”

Health care quality and prevention

Missouri landed in slot 35 of 51 for this category, which includes c-section rates, preventative care, pre and post-partum care and mental health screenings. 

In better news, Missouri ranked 15 of 51 among states with the lowest rates of c-sections during  low-risk births, which Kuykendall attributed in part to the state health department’s increased focus on doula programs.

Missouri was slightly below the national average for the percentage of women eligible for mammograms who underwent the breast cancer screening in the past two years (75%), and the percentage of women ages 21 through 65 who had a pap smear, which screens for cervical cancer, in the past three years (78%).

Among the more concerning data points to Kuykendall was a report that 19% of women between the ages of 18 and 44 in the past 12 months had put off seeing a doctor because of the cost. 

This data resonates with what she hears often from Missourians, who say it can be difficult to access even the most basic health care for reasons including cost, lack of transportation and lack of options.

“It was a positive step that Missouri expanded Medicaid,” Kuykendall said, “And I think we have a long way to go in terms of ensuring everyone who should have access to care in that new environment actually does.”

Saira Khobab and her 8-year-old son, both of whom were cut from Medicaid and struggled to re-enroll, walk into a pediatrician's office in Kansas City on July 11 (Clara Bates/Missouri Independent).

Dr. Maya Moody, a community pediatrician in St. Louis, knows a new month has begun when her clinic’s billing department runs patients’ names and she hears about the children no longer covered by Medicaid. 

One of those patients, now 3 years old and deaf in one ear, was scheduled for a cochlear implant. But when his family unexpectedly lost Medicaid last year, they had to cancel the appointment. 

Delays getting their coverage reinstated and securing another specialty appointment set the procedure back by around a year.

“And now,” Moody said, “he has developmental delays because he wasn’t getting all of his services that he needed for his hard-of-hearing.” 

Other parents, she said, don’t learn their child lost Medicaid coverage until they reach the clinic’s front desk. And though they quickly submit paperwork to get coverage back, it can be months before it’s reinstated.

Since June of last year, Missouri has been re-checking the eligibility of all Medicaid enrollees, after a three-year federal pause due to the COVID-19 pandemic. 

The Medicaid rolls are down by roughly 136,000 kids since the process of recertification started up again. Many qualify for coverage but are losing out due to paperwork or “procedural” reasons.

And in recent months, the state’s application processing times for Medicaid have gotten so long the federal government was compelled to intervene to help Missouri improve the situation.

In the meantime, thousands of children who lost coverage are dealing with delayed or foregone medical care, which can include missed vaccines for infants, preventative care and prescriptions for chronic diseases like asthma and diabetes — doctors, families and advocates told The Independent.

“While we’re waiting for this bureaucratic process of solutions and people sitting at tables talking about procedural issues, I’ve got kids in my office who are suffering poor health outcomes, delayed care,” Moody said. “It’s just heartbreaking.” 

Worst-in-nation processing delays

Over the last year, the state’s Medicaid rolls shrunk by 249,209 people. Over half of that decline was children, even though children are eligible at higher income levels.

Of Missourians who lost coverage between June 2023 to May, state data shows nearly 80% were for a “procedural” issue, and the rest were no longer eligible. 

Procedural issues generally refer to paperwork issues, meaning a participant failed to return paperwork or the state didn’t receive it. Those can include people not understanding the forms, not receiving them because of a change in address or the state losing the paperwork upon receipt.

As the state evaluates hundreds of thousands of current Medicaid recipients each month and processes their updated information, it continues to receive new applications — some of which are from people who were cut and trying to get back on.

Federal data shows Missouri’s application processing times have been among the worst in the nation since late last year.

Medicaid applications are generally required to be reviewed within 45 days. Nationwide, most applications were processed within 24 hours last year.

But more than half of applications took longer than 45 days to process in Missouri between December and March, the most recent available data. In February, that portion was 72% and in March it was 64%. 

Nationally, only 14% of applications took longer than 45 days to process in March. 

The federal Centers for Medicare and Medicaid Services wrote in a May letter obtained by the Independent that it is concerned the state is not doing enough to “achieve and sustain” compliance with federal rules on Medicaid and is intervening to help Missouri identify strategies to come back into compliance. 

The Department of Social Services, which oversees the state’s Medicaid program, declined to comment for this story.

Kids hospitalized because of Medicaid lapses

Dr. Thuylinh Pham, a pediatric urgent care doctor in Kansas City, said she’s been seeing kids come in who have had Medicaid lapses and “can’t afford their chronic medications.”

Some families are unable to get a primary care appointment because they’re no longer insured, and don’t go to the ER because they’re worried about the cost.

“These kids are coming in really, really sick,” Pham said. “We’re having to call 911, we’re having to get transport and get them into the hospital, and the reason for a lot of it is they want to avoid a bill, and so that is a really dangerous situation for these kids.”

Asthma medications out of pocket can cost over $100 per month.

“We are seeing kids who have been out of their medications for months and may have been well-controlled on the medications, but now…they’re being hospitalized for it because of Medicaid lapses,” she said.

Dr. Heidi Sallee, a pediatrician in St. Louis who is also president of the Missouri chapter of the American Academy of Pediatrics, remembers a specific patient’s deterioration.

A 5-year-old asthmatic girl was recently cut from Medicaid and her family couldn’t afford refills of her prescription. The girl ended up in the emergency room two times while waiting to be reinstated, Sallee said.

At one point, her mother had tried to fill a room with steam to ease the girl’s symptoms, but she stopped breathing and was rushed to the emergency room in an ambulance.

“If she’d been able to stay on her Medicaid and not have that interruption, she would have been on her medicines and would likely have not had that asthma exacerbation that then brought her to the ER two times,” Sallee said.

Parents’ difficult calculations

Dr. Shanon Luke, who for the past three years worked as a pediatric resident in Columbia, said she’s seen disenrolled families postpone preventative care, such as getting lab testing done to determine the cause of a child’s slow physical growth.

“It can be frustrating just wanting to provide the best care for the patient, but having this barrier,” she said, “…seeing the difficulty that they had in making the decisions on what to do for their kid because they were concerned about finances was just really sad.” 

Several pediatricians mentioned patients driving from hours away, from rural areas without pediatricians who take Medicaid, only to be turned away for lack of coverage.

Missouri Ozarks Community Health is a federally-qualified health center with six clinics in rural south-central Missouri. It offers limited pediatric care, said CFO Randall Gann, and is primarily seeing the current Medicaid issues in kids’ dental care, where they provide services for many more kids.

Gann said he’s seeing patients waiting five or six months to get dental care, after they’re disenrolled and try to come back on — and that those delays have gotten worse the last few months.

“We have a lot of parents making decisions right now to not pursue dental care for their kids,” he said, “unless, you know, they get on the Medicaid status and can actually get approved before bringing them back in.” 

A ‘multitude of systems issues’

Parents and advocates trying to get answers from the state about their coverage issues often run up against seemingly insurmountable barriers. 

The state has long been grappling with technology issues, including a dysfunctional call center, and staffing issues. 

LaNetta Nole, a mother of two living in Malden, in the southeast part of the state, has been trying to get her kids — a 14-year-old son and 10-year-old daughter — back on Medicaid since February. 

She works at Pizza Hut and her husband works as a mechanic. His employment health care plan would cost $500 per week to add her children, she said.

Her son got braces in December but hasn’t been able to go back to the orthodontist for his monthly routine checks and adjustments because he’s uninsured. Each visit to the orthodontist costs $170 without insurance, she said.

“We don’t have that,” she said. “…I don’t even have that to take him back to the orthodontist and he needs to go.” 

Cole has called the state each month since January. She has waited up to four hours on the phone to connect with a representative. 

When she tried going to her in-person Family Support Division office in East Prairie earlier this year, she said she was directed to a booth and told to wait for a call. She didn’t have time to wait beyond 20 minutes. 

“I’m so confused by it, and I’ve wracked my brain trying to figure out why they have not been reactivated,” she said, “Because I submitted everything.” 

Advocates who help people with their Medicaid enrollment issues say they’ve been frustrated the state hasn’t taken more action to address problems that have been there for the last year.

Joel Ferber, advocacy director at Legal Services of Eastern Missouri, said they’ve noted a “multitude of glitches and systems issues,” including with the state failing to process documents in a timely way, losing documents and people being kicked off due to computer errors. 

They’ve seen “so many newborns without coverage for more than a month missing doctor’s appointments,” Ferber said.

Jim Torres, program manager for health insurance services at Samuel Rodgers Health Center in Kansas City, said after he helps clients get their information to the state, “it’s hitting a brick wall,” often taking months to have the state register simple changes.

“Patients sometimes come back to us and say well, I gave you the information to send in. Didn’t you send it in?” Torres said.

“Yes, I did,” he replies. “It’s sitting on their computer system, it hasn’t been worked.”

Some women, Torres said, give birth before they finally are able to get switched from adult Medicaid to the pregnancy Medicaid category, which covers important services like prenatal visits.

“It’s a broken system,” Torres said “I think they’re dedicated hardworking public servants but the system just isn’t working.”

Ripple effects

Saira Khobab, a mother in Kansas City, spent the last month calling Torres in a panic.

At the optometrist in May, when Khobab went to buy a pair of glasses for her 6-year-old daughter, she was told her Medicaid had been deactivated. The glasses would cost around $200 out of pocket, which the family — her husband works overnight shifts at a gas station — couldn’t afford.

She worried her daughter wouldn’t be able to see the blackboard at school next month.

Her daughter, her 3-year-old son, 8-year-old son and Khobab all lost Medicaid coverage after the family’s annual renewal in April, even though they meet the income requirements for eligibility and Khobab remembers submitting the required paperwork. 

Her youngest son has several health problems. Khobab needs care, too, that she’s had to delay — she fell twice while pregnant, gave birth in May, and has had trouble walking. She needs to go to physical therapy, she said. 

“Especially after I gave birth, it’s been really stressful,” she said. 

Late last week, she finally got news their coverage had been renewed.

“I’m happy for her,”  Torres said, “because I could sense the frustration and the worry in her voice — ‘kids are sick, they have dentist appointments, doctor’s appointments, how are we going to do this?’”

The saga isn’t over. Bills are piled up on her dining room table for appointments she is relying on Medicaid to backpay, now that they’re finally reinsured. 

And she rattles off the specialty appointments she’ll need to make now for herself and kids. She worries about what will happen in the months of waiting for openings.

“Tomorrow,” she said, “I will call when my card is active. I’ll call and see what we are going to do.”

A federal judge put a Missouri law on hold that would prevent pharmacists from alerting patients that some medicines they’ve been prescribed are debunked for treating COVID-19. But the state pharmacy board just posted guidelines about it anyway (Mint Images/Getty Images).

A politically charged Missouri law that would prevent pharmacists from counseling patients or doctors about ivermectin and hydroxychloroquine, two treatments that have been debunked for COVID-19, has been on hold for two years in federal court.

Yet the Missouri Board of Pharmacy posted a guidance statement at the end of June that doesn’t mention that the law is on hold pending legal challenge.

The guidance tells licensed pharmacists that state law bars them from “contact(ing) the prescribing physician or the patient to dispute the efficacy of ivermectin tablets or hydroxychloroquine sulfate tablets for human use.”

Gov. Mike Parson signed it into law in June 2022, soon after COVID deaths had reached 1 million in the United States. The law drew criticism across the pharmacy and medical professions that saw it as a government-imposed gag order.

A St. Louis pharmacist filed a lawsuit the next month to stop the law. Ashley Stock sued members of the state pharmacy board, arguing that the law violated her First Amendment rights and should not be enforced.

Missouri governor signs law shielding doctors prescribing ivermectin, hydroxychloroquine

As a retail pharmacist, Stock said in her complaint, her job was to consult with patients and doctors about medications, doses and potential interactions.

She said she had confronted doctors who had prescribed hydroxychloroquine, an anti-malarial drug, or ivermectin, an anti-parasitic medication, about the drugs’ effectiveness against a virus.

“If, after Stock’s discussions, the prescribing physicians or patients insisted on seeking (the medications),” her lawsuit said, “Stock sometimes refused to fill those prescriptions.”

The U.S. Food and Drug Administration continues to advise that ivermectin is not authorized or approved to treat COVID-19, nor has it been determined to be “safe or effective.” In 2020, the FDA warned that hydroxychloroquine could cause heart rhythm problems and should not be used outside a hospital setting. The drug also does not work to treat or prevent COVID.

But using both drugs to fight the virus — as then-President Donald Trump hyped them — became touchstones for some conservatives.

By restricting how pharmacists can do their jobs and how they treat patients, Stock and other pharmacists have argued, the law could set a dangerous precedent and damage their ability to act as important watchdogs for patients’ health care, such as noticing potential allergies, drug interactions or other risks that might have been overlooked by a doctor.

A federal judge granted a temporary injunction in response to Stock’s complaint in August 2022. This summer, both sides filed motions that would dismiss the case in their favor without a trial.

While that’s pending, the law is not in effect.

Matthew J. Tkachuk, the assistant state attorney general defending the pharmacy board in the lawsuit, said the guidance posted on the board’s website on June 26 offers insight about how the board plans to enforce the law if the judge allows it to take effect.

“Essentially, the guidance statement is not practically effective until the court … rules in our favor on summary judgment,” Tkachuk said. “It provides a lot of clarification and, to some extent, qualification, that might allay some pharmacists’ concerns.”

The board’s guidance says the 2022 ban on pharmacists proactively contacting doctors and patients about ivermectin and hydroxychloroquine should be seen within the context of the entire statute that governs how pharmacists are regulated.

The guidance points out that pharmacists should not provide false, misleading, deceptive or dishonest counseling.

“This would include initiating contact with a prescriber or patient to dispute that ivermectin or hydroxychloroquine are efficacious for human use as approved by the FDA,” the board guidance says.

It also says the law change passed two years ago “does not prohibit a pharmacist from sharing truthful and accurate medical/drug information with prescribers or patients, consistent with the standard of care, current FDA guidance, or evidence-based scientific data/research.”

The guidance does not give any indication that a federal judge could decide to strike it from the state statute. It also doesn’t acknowledge the court injunction that’s at least temporarily nullified the change.

Besides that, said Adam E. Schulman, the Virginia lawyer representing Stock, board guidance doesn’t hold the same weight as law.

“They’re trying to get the judge to change his mind,” Schulman said. “But (guidance) doesn’t change what is on the books.”

This article first appeared on Beacon: Missouri and is republished here under a Creative Commons license.

President Joe Biden tested positive for COVID-19 on Wednesday, July 17, 2024. In this photo, he holds a news conference at the 2024 NATO Summit on July 11, 2024 in Washington, D.C. (Kevin Dietsch/Getty Images).

President Joe Biden tested positive for COVID-19 on Wednesday, according to statements from White House press secretary Karine Jean-Pierre and the president’s doctor.

“Earlier today following his first event in Las Vegas, President Biden tested positive for COVID-19,” Jean-Pierre wrote in her statement. “He is vaccinated and boosted and he is experiencing mild symptoms.”

Biden will return to Delaware to isolate while continuing to work and the White House will provide “regular updates,” she said.

An accompanying statement from the president’s physician said that Biden began experiencing a runny nose, cough and “general malaise” on Wednesday afternoon.

“He felt okay for his first event of the day, but given that he was not feeling better, point of care testing for COVID-19 was conducted, and the results were positive for the COVID-19 virus,” the doctors statement said, later adding that a PCR confirmation test is pending.

“His symptoms remain mild, his respiratory rate is normal at 16, his temperature is normal at 97.8 and his pulse oximetry is normal at 97%,” the doctor said. “The President has received his first dose of Paxlovid. He will be self-isolating at his home in Rehoboth.”

Biden arrived at the Las Vegas, Nevada, airport around 3:20 p.m. local time to fly back to the East Coast, according to a White House pool report.

The president said he felt “good” before walking “cautiously up the stairs” to Air Force One, according to the report.

Biden previously tested positive for COVID-19 in July 2022 before being diagnosed with a rebound case later the same month.

Hens are often held in stacks of cages in large egg-laying facilities. (Photo via Getty Images)

Soaring temperatures made it difficult for farm workers to protect themselves from chickens recently infected by avian influenza in Colorado and likely contributed to five people contracting the virus, according to the U.S. Centers for Disease Control and Prevention.

State health officials discovered the infections last week — the largest cluster of human infections in the country since the bird flu outbreak began more than two years ago.

Human infections are of great concern to public health officials because they increase the likelihood that the virus could mutate to easily pass from person to person and spur a human pandemic. A total of 10 infections among people have been discovered since April 2022.

But the virus found in the Colorado workers does not possess such a mutation, said Dr. Nirav Shah, principal deputy director for the CDC, in a Tuesday call with reporters. It’s believed they were each infected by egg-laying chickens as they sought to cull a flock of about 1.8 million in the northeast part of the state.

It is customary to kill entire flocks when they are infected by highly pathogenic avian influenza — which readily infects and kills poultry — to prevent its spread to other flocks.

The Colorado workers grabbed the chickens, placed them into containers that can hold dozens at a time, and asphyxiated them with carbon dioxide, said Dr. Julie Gauthier, executive director for field operations for the U.S. Department of Agriculture’s Animal and Plant Health Inspection Service.

The workers typically wear suits, goggles, gloves and boots, and they breathe through respirators that protect them from pathogens.

But the outdoor temperature at the time of the work was about 100 degrees, and the temperature inside the facility was likely hotter. Giant fans moved air to cool the inside, which circulated potentially virus-laden debris such as feathers.

“The difficulty with wearing all that gear in that kind of heat, you can imagine,” Gauthier said, “and it was made more difficult by those fans pushing the air — made it hard to keep those goggles and N95 respirators in place.”

The virus that infected the flock is similar to one that has infected dairy cattle in 13 states, Shah said. Colorado has had the most infected herds of any state, with at least 37. It’s possible that the virus was transported to the egg-laying flock from one of those herds, Shah said.

Highly pathogenic avian influenza has been spread by wild birds and has been sporadically devastating for U.S. poultry flocks since January 2022. About 99 million birds in infected flocks have been destroyed, according to CDC data.

Federal officials believe the virus passed from wild birds to Texas dairy cattle in December. Since then it has spread to herds in other states, likely due to the transportation of infected cattle. From there it is believed to have spread locally to other herds and poultry flocks via people and their equipment, including farm workers and veterinarians.

Colorado accounts for seven of the 10 known human infections in the United States that were the result of interactions with sick birds and cows. It had the first-ever infection of a poultry worker, in April 2022. Early this month, a Colorado dairy worker was also infected.

The workers who were recently infected had mild symptoms of pink eye and respiratory illness.

This story was originally published by the Iowa Capital Dispatch, a States Newsroom affiliate. 

Iowa State University researchers have identified receptors for the avian flu on dairy cattle mammary glands. (Photo courtesy of the U.S. Department of Agriculture)

As avian influenza is being detected in more and more dairy herds across the U.S., Iowa State University researchers have found a possible “why” connection to the virus being found in raw milk.

A study published this month by a team in ISU’s College of Veterinary Medicine found that bovine mammary gland tissue held receptors for the avian influenza virus, offering a potential explanation for how cattle are being infected.

Todd Bell, a professor of veterinary pathology and co-author of the study, said the idea to look at mammary glands as a potential entry point for the virus came after it was identified in raw milk. Two ISU alums in the spring identified an illness impacting cattle in Texas as avian flu, and ever since different teams at the university and in partnerships with other organizations have been working to tackle the virus and its spread from different angles.

“They really answered the ‘what,’ what was actually going on, what was making these cattle sick, which is a new and novel finding, and then our job, really, at that point as researchers was to understand the ‘why,’” Bell said. “We’ve never seen this before. Why is this happening?”

To understand the concept, Bell suggested thinking of viruses as like keys, and receptors are like locks to cells. In order for the avian flu virus to enter a cell and reproduce, it needs the right receptor. The research team found that receptor on cattle mammary glands.

Another receptor they found is connected to human influenza, Bell said, which is important because it opens up the possibility of a cell being infected by both viruses, potentially causing the creation of a new virus.

“To our knowledge, that hasn’t happened yet in this particular outbreak, but we wanted to look for those receptors to understand what might be possible and hopefully stop the transmission and stop that from happening,” Bell said.

The team also looked at the respiratory system to try and identify evidence of the bird flu, but found little there, narrowing down the possibilities of how cattle are being infected.

According to the American Veterinary Medical Association, as of July 12 the avian influenza had been detected in dairy herds in 12 states, including 13 herds in Iowa. While the virus is being detected in raw milk, the pasteurization process ensures it is safe to be consumed.

Research may inform preventative policies

While Bell and his colleague’s work is still very much focused on the “why” of avian flu in dairy herds and its spread, he said the hope is that their research will help inform regulators in making decisions on testing and biosecurity measures to try and stop the spread of the virus. He said there is some literature that states the virus can live on milking machines for a few hours after an infected cow is hooked up to them, offering one potential method of spread.

“We hope that what we find will help them make those types of decisions, specifically if we can find it in mammary tissue, then how do we stop it from getting to that mammary tissue in the first place,” Bell said.

Next steps for Bell and his colleagues include looking at the milk and mammary glands of other domestic animals, like sheep and goats, to see if they also carry receptors for the avian flu. Bell said they will also look at their respiratory systems and gastrointestinal tracts to see if the flu could have other points of entry, like if a wild bird with the virus defecates into a water supply and farm animals drink the infected water.

Iowa Secretary of Agriculture Mike Naig said during “Iowa Press” last week that longitudinal studies are also being conducted on farms to test every single animal housed there in order to track how the virus moves and determine how it exits the herd.

“Because it will, it will eventually exit that herd and you want to be able to track those things and have an expectation of how long does that last,” he said during the program.

This story was originally published by the Iowa Capital Dispatch, a States Newsroom affiliate. 

Some anti-abortion organizations call Plan B, which is an emergency contraceptive designed to prevent pregnancy after unprotected sex, an abortion drug because it can prevent the implantation of a fertilized egg (Illustration by Justin Sullivan/Getty Images).

Clinic closures in the wake of the Dobbs decision and questions about the legality of emergency contraceptives, including disinformation that some are abortion drugs, may have contributed to a sharp drop in the rate of prescriptions for contraceptives in states with the most restrictive abortion bans, according to a University of Southern California study.

The decline was significant in most states with restrictive bans following Dobbs in June 2022 that returned regulation of abortion procedures to the states, the study found. The group of researchers, led by pharmacy professor Dima Qato, used data from national prescription audit databases to estimate the monthly volume of prescriptions dispensed at pharmacies nationwide and state-by-state. It represents estimates from more than 93% of retail pharmacies.

“Given that abortion would be restricted in many states even more after Dobbs, I wondered whether now more people would get covered through contraception to prevent pregnancy and the need for an abortion,” Qato said.

Over the past six months, especially in states with near-total abortion bans, lawmakers have discussed proposals that would protect access to contraception, but those efforts have largely failed because of concern over whether that would include emergency contraception. Some anti-abortion organizations call Plan B, which is an emergency contraceptive designed to prevent pregnancy after unprotected sex, an abortion drug because it can prevent the implantation of a fertilized egg.

The researchers think those conversations have led to confusion among residents who aren’t sure if emergency contraceptives are still legal in their state. That confusion could also extend to pharmacists. While Plan B is available over the counter at many retail stores and pharmacies, including Amazon, it can also be obtained by prescription, which is the only data point the study captured. According to the research, the rate of obtaining it through prescription between 2021 and 2023 dropped more than 70% in four states with near-total bans — Arkansas, Kentucky, Louisiana and Tennessee. It declined by about 60% in Missouri.

The increases peaked in July 2022 and then dropped to levels lower than the pre-Dobbs period, Qato said.

“For patients that are seeking emergency contraception but can’t get it prescribed or filled, that’s where it matters,” Qato said. “They want to take it, they know it’s an option, and now they’re faced with hesitant prescribers and pharmacies.”

Half of women surveyed in ban states are unsure if Plan B is legal

A Kaiser Family Foundation poll released in early 2023 found that more than 30% of adults surveyed were unsure if Plan B was legal in all 50 states and over the counter — and half of women living in states with abortion bans were under the impression that emergency contraceptives were illegal or were unsure if they were legal.

Conversely, in two states with near-total bans, Idaho and South Dakota, the rate of prescriptions for emergency contraceptives increased by 148% and 182%, respectively. Those numbers were attributed to increases in ulipristal, which is also known as Ella, rather than levonorgestrel, known as Plan B. Ella can be effective at preventing pregnancy up to five days after unprotected sex, while Plan B is most effective within three days and is also less effective in people who weigh more than 165 pounds, while Ella does not have that limitation.

Between the 12 states with the most restrictive bans, the combined decline of emergency contraceptive prescriptions was 60%, and the decline for oral contraceptives was 24%.

Qato said she expected to see lower rates of emergency contraceptive use in the most restrictive states, particularly with the conversations likening them to abortion drugs, but she wasn’t expecting to also see a drop in monthly oral contraceptive prescriptions. Among states with the most restrictive bans, the largest decrease of 28% was in Texas, while most other states had decreases of about 20%, including Kentucky, Louisiana, Alabama and Tennessee.

Qato also theorized that the closure of abortion clinics in those states with bans contributed to the decreases, since most clinics that provided abortions prior to Dobbs also offered prescriptions for oral and emergency contraceptives, IUDs and other family planning services such as screenings for sexually transmitted diseases. The study found no change in the use of IUDs and other forms of contraception such as the patch or vaginal ring.

Over-the-counter options only help certain people 

In her research, Qato noted that two years after Iowa imposed Medicaid coverage restrictions on family planning clinics that provided abortions, the use of contraceptives declined by two-thirds.

A report from the Guttmacher Institute released this week showed 42 clinics that provided abortions nationwide closed their doors between 2020 and 2024. The number of abortions have also increased during that time, and more than 80% still take place at brick-and-mortar clinics rather than via telehealth or by mail.

While Plan B and Opill — an oral contraceptive — are available over the counter, Qato said those options are still untenable for some people who need contraceptives the most, including low-income women and women of color.

“Opill is convenient for those who don’t want to go to the doctor and have that discretionary income to purchase it, but low-income women relied on clinics that are now closed, they relied on prescriptions that they now don’t have,” Qato said. “Those options are accessible, but not affordable to women who could really benefit from it.”

While Qato said there should be a focus on restoring and protecting access to abortion, there should also be efforts to protect contraception in the most restrictive states. She is alarmed to see initial increases after Dobbs and then such steep declines.

“It suggests that we may observe increases in live births from unintended pregnancies in women who were forced to have a child that wasn’t planned because the state didn’t protect or introduced fear of criminalization or liability for patients, doctors, or pharmacists,” she said. “A woman may not feel safe choosing emergency contraception in those states anymore.”

CORRECTION: This story has been updated to correctly identify the University of Southern California as the institution that conducted a study that found a sharp drop in the rate of prescriptions for contraceptives in states with the most restrictive abortion bans.

Missouri Medicaid just added coverage for routine dental exams (Suzanne King/The Beacon).

Missouri Medicaid began covering teeth cleanings, and almost no other routine dental work, for adults a few years ago.

But the bill for the dentist actually peering in your mouth to check teeth and gums went to the patient.

While some dentists wrote off the cost of the dental exam, many patients just stayed away from the dental chair and the potential bills it represented.

That changed July 1, when routine dental exams for adults were added to the state’s Medicaid coverage.

Health experts said it is a significant step in the state’s multiyear effort to improve dental access — and to boost overall health, beyond cavities, molars and gums.

“I was doing cartwheels when I heard that they were going to cover that,” said state Director of Oral Health Dr. Jacqueline Miller.

The move came less than a decade after Missouri restored limited adult dental benefits under MO HealthNet, the state’s Medicaid plan. And two years after it significantly increased the rates the plan pays dentists.

Although MO HealthNet still doesn’t cover expensive services like dentures and crowns, the state has gone from being one of the worst in the country for dental access two years ago to a model for other states.

In 2023, an additional 50,000 Medicaid recipients in Missouri got dental benefits. And 184 new dental offices began accepting Medicaid.

“We’ve seen changes in other states based on what has happened in Missouri,” said Dr. Aaron Bumann, a pediatric dentist in Liberty who serves as a public policy advocate for the Missouri Academy of Pediatric Dentistry. “That’s positive peer pressure.”

Inequities in access

For decades, public health experts complained that too many Americans couldn’t afford to see a dentist. Skipping checkups, they said, could put their overall health in peril.

In 2000, then-U.S. Surgeon General David Satcher commissioned a report that warned about who could and couldn’t get dental care. Twenty years later, a follow-up report from the National Institutes of Health said the same problems persisted.

“Oral health care has not been, and is not,” the report said, “equitably available across America.”

Low-income Americans are more likely to have untreated dental problems, which can spiral into bigger health and social issues. Even when people had dental insurance, they often put off or skip dental care because of the high out-of-pocket costs.

A 2023 KFF survey found that was true for 38% of adults on Medicaid, 37% of adults who got insurance through the Affordable Care Act marketplace, 26% of those covered by Medicare and 25% of adults with employer-sponsored insurance.

More than shiny white teeth

“There’s this general kind of belief for some people that dental isn’t actually health care,” said Gary Harbison, executive director of the Missouri Coalition for Oral Health. People think “it’s maybe more about white, shiny, straight teeth.”

But science is increasingly clear that oral health care is critical to overall health.

“It’s a mistake to let it go and think, ‘That is an extra. I’ll take care of it later,’” Harbison said.

In addition to uncovering cavities before they grow into serious dental problems, regular dental exams can reveal cancer diagnoses and symptoms of other serious conditions like diabetes and heart disease. Lack of oral health care can also affect mental health, experts said.

“You can’t be healthy without having good oral health,” said Dr. Megan Krohn, executive director of dental services for Swope Health. “It’s a right. As we fight for having health care access for all, part of that needs to be oral health care access also.”

Swope Health, a community health center that gets federal aid to serve as a safety net for uninsured patients, operates clinics that provide dental and other health care services in both Missouri and Kansas. The contrast in access in the two states is stark, Krohn said.

For one thing, Kansas has not expanded Medicaid, leaving nearly 250,000 adults in the state without any health care coverage. Missouri voters passed Medicaid expansion in 2020, bringing some 275,000 more Missourians onto the rolls the following year. That strained the dental providers who accepted the state’s Medicaid.

Jessica Emmerich, dental Medicaid facilitator with the Missouri Coalition for Oral Health, said in 2022 the state had 700 dental providers for 1.3 million Medicaid participants.

“We needed more dental providers to get on board,” she said.

Reimbursement rates are key

The state bumped the reimbursement rate it pays Medicaid providers in 2022 from around 30% to 80% of the usual and customary rate, or the same as private insurance.

Before the rate increase, Bumann said, “the reimbursement rates didn’t cover overhead, so dentists didn’t participate.”

Now the state has more than 1,000 providers who take Medicaid. Getting dentists to accept Medicaid benefits is key to expanding access, experts said.

Kansas reimbursement rates still hover around 35%.

“It’s hard to convince and encourage dentists to provide coverage under that program,” said Kevin Robertson, executive director of the Kansas Dental Association.

With low reimbursement rates and without Medicaid expansion, many Kansans rely on free dental care or places that cut rates for low-income patients. But that typically means waiting weeks or months for appointments.

Vibrant Health, a community health center in Kansas, can’t keep up with the demand it sees for dental care, said Dr. Anthony Jimenez, Vibrant’s vice president of dental services. The clinic is working to hire a fifth dentist, but that won’t begin to meet the need, he said.

“As soon as we hire this person,” Jimenez said, “their schedule would be full almost immediately.”

Since the changes to Missouri’s Medicaid coverage, 60% of patients who come to Swope Health’s dental clinics are covered by Medicaid, while 40% are uninsured. On the Kansas side, Krohn said, 85% of patients are uninsured.

States decide on dental coverage

States are required to pay for dental care for people younger than 21 enrolled in Medicaid. But for now, they can decide how to handle adult coverage. Traditionally, dental coverage has been seen as an add-on that many states decide not to spend money on.

Missouri reinstated limited adult dental coverage through Medicaid in 2016. At the time, coverage for dental cleanings, a one-time exam and a few other services like X-rays and fillings, were added. But not exams in following years. The gap meant many went without care.

But preventive care is vital in dentistry, experts said. Major dental problems can most often be prevented if caught early, which is why regular screenings — like the ones MO HealthNet is now covering — are crucial.

“You can fix a small cavity with just a filling,” Jimenez said. “But by the time the patient is aware of it, by the time it’s keeping them up at night, at that point it’s a much bigger problem.”

Changes like the ones in Missouri may begin to move the needle so more people get help sooner.

“The fact that we’re starting to see more coverage for adults is a huge win,” said Dr. Steven Haas, dean of the University of Missouri-Kansas City School of Dentistry. “It’s a very big win.”

And more change could follow. Just this spring, the Centers for Medicare and Medicaid Services said states could designate routine dental benefits for adults an essential health benefit, a service that must be covered under the Affordable Care Act.

This article first appeared on Beacon: Missouri and is republished here under a Creative Commons license.

The U.S. Department of Agriculture has performed more than 17,000 tests for avian influenza on cattle, with 139 dairy herds throughout a dozen states (Getty Images).

WASHINGTON — As the number of dairy cows infected with a strain of bird flu virus grows across the country, 17 of Missouri’s roughly 60,000 dairy cows have been tested while agriculture officials and farmers keep watch for signs that the outbreak has entered the state.

So far, Missouri farmers haven’t reported any cows with the virus, called H5N1, state officials said.

However, national biosecurity and public health experts are concerned that a lack of testing in states across the country, and the economic implications of quarantining cattle, may be allowing the virus to spread undetected.

“You want to work on the assumption that it’s there, and you’re trying to find it,” said Amesh Adalja, a senior scholar at Johns Hopkins Center for Health Security, who focuses on pandemic policy and the intersections of infectious disease and national security. Adalja said 17 tests aren’t enough to give him confidence that Missouri’s herds are virus-free.

“Just because you’re not looking, doesn’t mean it’s not there, that you’re going to avoid the consequences,” Adalja said.

Missouri State Veterinarian Steve Strubberg acknowledged that only a small fraction of the state’s dairy cows have been tested for the virus. Strubberg, who leads the Missouri Department of Agriculture Animal Health Division, said he believes Missouri farmers would have reported sick cows to their veterinarians if their herds were becoming infected.

Because H5N1 is a “Reportable Disease,” veterinarians and laboratories are required to disclose detections. However, while farmers are encouraged to report H5N1 symptoms, it’s not a requirement because there is no confirmation they are ill with the H5N1 virus.

“We just feel like most livestock producers, they really do a great job of watching the health of their animals,” Strubberg said. “I mean, it’s their livelihood.”

Health experts investigating the H5N1 outbreaks in Texas and Colorado told The Associated Press that because labs must report positive results to agriculture departments, many farmers may decide against testing and try to outlast the outbreak to avoid a negative stigma.

In dairy cattle, the virus causes low appetite and reduced milk production, and the milk can have an abnormal appearance. Occasionally, farmers have cows with similar symptoms, which can also be caused by other diseases.

In 2023, a federal appeals court ruled that nothing in federal law prevents pharmacy manufacturers from limiting the number of contract pharmacies they will supply with 340B discounted products (Getty Images).

A bill favoring Missouri pharmacies and health care providers in a national dispute with drugmakers will become law without Gov. Mike Parson’s signature.

The legislation, which passed both chambers with veto-proof majorities, bars pharmaceutical manufacturers from limiting where they will deliver drugs purchased at a discount under a federal program intended to help providers serving people in rural and high-poverty areas or with specialized health needs. 

It allows medical providers qualifying for the program, known as the 340B Drug Pricing Program for the section of federal  law where it is found, to enter contracts with an unlimited number of pharmacies to dispense the drugs to their patients.

The bill is “flawed,” Parson wrote in a letter explaining his action, but ultimately is better for patient access and affordability than if he vetoed it.

“Most troubling, the 340B program lacks requirements for cost savings to be passed onto patients and further lacks transparency as to how those cost savings are used,” Parson wrote.

Parson made his decision as he announced action on the last of 26 non-budget bills passed during this year’s legislative session. He had 45 days – until Sunday – to make his decisions and any bill not signed and not vetoed becomes law as if he had signed it.

Parson did not veto any bills.

The stakes nationally in the 340B program are huge, in a medical market with escalating prescription prices and increasing concentration of medical providers in direct employment by hospital groups. Nationally, pharmaceutical manufacturers sold nearly $100 billion in discounted drugs in 2021 and 2022 through the 340B program.

In 2023, a federal appeals court ruled that nothing in federal law prevents pharmacy manufacturers from limiting the number of contract pharmacies they will supply with 340B discounted products. But those limits go only so far, the 8th Circuit Court of Appeals in St. Louis ruled when it upheld an Arkansas law – very similar to the bill passed in Missouri – that bans manufacturer-imposed limits on contracts.

“The use of contract pharmacies by covered entities under the program – among other programmatic concerns – is an issue that should be addressed by Congress,” Parson wrote. The legislation, while laudable in intent, “ensures the expansion of a flawed federal program within the state of Missouri.”

Because many health care providers did not have in-house pharmacies when the 340B program was begun in 1992, a change in 1996 allowed a single contractor for each provider. That was expanded starting in 2010 to allow unlimited contracts.

The number of contract pharmacies grew from 2,321 in 2010 to 205,340 in 2024.

Pushing back against the growth, pharmaceutical companies have targeted the program’s use by “disproportionate share hospitals,” generally serving large populations of patients without insurance or on Medicaid or Medicare. Those hospitals account for about 80% of all drugs purchased through the 340B program, $41.8 billion in 2022 and $34.3 billion the year before.

Those hospitals should be required to show how they use the money to help the patients that cannot pay for doctor visits and medications, Nicole Longo, deputy vice president of public affairs at PhRMA, the lobbying arm of the pharmaceutical industry, said in an interview last month with The Independent.

“They buy low and they sell high,” Longo said. “Patients bear a lot of that cost, and so that’s a major concern of the industry.”

In a statement, Stami Williams, PhRMA spokesperson, said the association agrees that the 340B program is flawed and in need of an overhaul by Congress.

The bill that will become law, she said, “does not help vulnerable patients more affordably access medicines. This legislation is a handout to large hospital systems, chain pharmacies, and pharmacy benefit managers (PBMs).”

The Missouri Hospital Association, in a statement following Parson’s action, said the legislation will maintain access to essential medications. The overwhelming majority in favor of the bill recognized that, said Jon Doolittle, the association’s president.

“In doing so, they rejected artificial limits on pharmacies’ participation, to ensure members of their communities could access their medication and health care services close to home,” Doolittle said. “In addition, they recognized that the 340B program supports services that would not otherwise be available in many communities without the protections added through the legislation.”

The program is essential for keeping rural providers open and giving patients access to prescriptions near their homes, said Joe Pierle, executive director of the Missouri Primary Care Association.

The association represents federally qualified health centers, which serve patients regardless of their ability to pay. The health centers are the second-largest group of providers using the 340B program.

“This whole contract pharmacy (issue) is really about allowing us to contract with local pharmacies so that patients in the Mark Twain National Forest can can drive a mile or two to pick up a prescription instead of having to traverse the hills and mountains down there, which are difficult to navigate, to sometimes go to a different county to get the drugs,” Pierle said.

Criticism of contract pharmacies is a smokescreen, he said.

“Their whole focus,” Pierle said, “was trying to get everybody’s focus off the massive profits that they’re making and the high cost for medications that Missourians are having to pay.”

(Photo courtesy of Missouri Governor's office)

Gov. Mike Parson signed legislation Thursday to make preventing veteran suicide a top priority for the state agency that aids these residents, the Missouri Veterans Commission. 

The suicide rate among Missouri’s veterans is nearly double the state rate and one of the highest in the country.

After three years of trying, Republican state Rep. Dave Griffith of Jefferson City said he was grateful for the governor’s support, along with the unanimous approval of both the House and Senate this spring. 

“I’m hoping that through House Bill 1495 we’re going to be able to take a deeper dive into what some of the causes are and some of the best practices we can learn from other states,” Griffith told the Independent this week.

The bill mandates the commission research procedures, treatment options and any other assistance to reduce the veteran suicide rate.

“The legislation we are signing today continues our commitment to our nation’s heroes that Missouri will remain one of the best places for veterans and service members to live, work, and raise a family,” Parson said in a news release.

In separate budget bills, lawmakers approved $120,000 for the commission to hire one or more people dedicated to the mission. 

Griffith said he spoke with retired Col. Paul Kirchhoff, the commission’s executive director, about next steps this week.

“He said, ‘We’re ready,’” Griffith said of Kirchhoff. “‘As soon as the governor signs the bill, we’ve got applications already on file for people who want to apply for that particular job.’”

Up until now, Griffith said the commission has implemented “as much as they can” to address the issue, while juggling their main duties.

The commission has long had three core missions of managing the veterans’ nursing homes and cemeteries and providing service officers who help veterans with their benefits, Griffith said.

The bill would add a fourth. 

“They really couldn’t devote as much time as they can now,” he said, “so creating that fourth priority for them will allow them to do that. It’s a good day for all veterans in Missouri.”

According to the legislation, the commission must file a report every year on July 1 with the Department of Public Safety and the General Assembly on the recommendations and implementation of its efforts. 

In 2021, Parson established an interagency team to collaborate on suicide prevention, so Griffith said he expected to receive the governor’s full support on the measure.

Kirchhoff told the House Veterans Commission in January that he embraces the new task, particularly because he’s lost several close military friends to suicide.

“This is near and dear to my heart,” Kirchhoff said. “We’re losing veterans every day to this. And whatever we can do to curb that, we’re all in.”

Many people can guess, he said, the reason Missouri has a higher rate than the national average. 

“But I’d like to know through facts,” he said. “And without having an emphasis on this, we just won’t know.”

Protesters gather outside the U.S. Supreme Court on Wednesday, April 24, 2024, while justices hear oral arguments about whether federal law protects emergency abortion care (Sofia Resnick/States Newsroom).

WASHINGTON — The U.S. Senate gridlocked over reproductive rights on Wednesday, when Republicans blocked Democrats from advancing a measure that would have expressed support for abortion access.

The failed 49-44 procedural vote was just one in a string of votes Senate Democrats are holding this summer to highlight the differences between the two political parties on contraception, in vitro fertilization and abortion ahead of the November elections.

Maine Sen. Susan Collins and Alaska Sen. Lisa Murkowski were the only Republicans to vote to move the bill toward final passage.

“This is a plain, up-or-down vote on whether you support women being able to make their own reproductive health care decisions,” Washington Democratic Sen. Patty Murray said during floor debate. “It doesn’t enforce anything. It doesn’t cost anything. It’s actually just a half-page bill, simply saying that women should have the basic freedom to make their own decisions about their health care.”

Minnesota Democratic Sen. Amy Klobuchar said that women and their doctors, not politicians, should make decisions about abortion and other reproductive health choices.

“This is our current reality, but it doesn’t have to be our future,” Klobuchar said. “This is a pivotal moment for America: Are we going to move forward and protect freedom, which has long been a hallmark of our nation, or are we going to go further backwards in history — not just to the 1950s but to the 1850s.”

Michigan Democratic Sen. Debbie Stabenow urged support for the legislation, saying women should be able to make decisions about their own health care, lives and futures.

“That’s what this vote is about and we’re not going to give up until we have those freedoms fully protected,” Stabenow said.

No Republican senators spoke during debate on the bill ahead of the vote.

The two-page bill would not have actually changed or provided any nationwide protections for abortion access.

The legislation, if enacted, would have expressed a “sense of Congress” that abortion rights “should be supported” and that the nationwide, constitutional protections for abortion established by Roe v. Wade “should be restored and built upon, moving towards a future where there is reproductive freedom for all.”

The Biden administration released a Statement of Administration Policy earlier in the week, backing the bill.

“Today, more than 20 states have dangerous and extreme abortion bans in effect, some without exceptions for rape or incest,” the statement said. “Women are being denied essential medical care, including during an emergency, or forced to travel thousands of miles out of state for care that would have been available if Roe were still the law of the land. Doctors and nurses are being threatened with jail time.”

Trio of bills offered, blocked

The blocked procedural vote on Wednesday came just one day after Democrats went to the floor in an attempt to pass three other bills on reproductive rights through the fast-track unanimous consent process.

That involves one senator asking “unanimous consent” to pass legislation. Any one senator can then object, blocking passage of the bill. If no one objects, the bill is passed.

The maneuver is typically used to approve broadly bipartisan measures or for lawmakers to bring attention to legislation without moving it through the time-consuming cloture process that can take weeks in the Senate.

Nevada Sen. Catherine Cortez Masto on Tuesday tried unsuccessfully to pass her bill, which would have barred the government from preventing travel “to another state to receive or provide reproductive health care that is legal in that state.”

Forty Democratic or independent senators co-sponsored the legislation.

During brief floor debate, Cortez Masto said the bill “reaffirms that women have a fundamental right to interstate travel and makes it crystal clear that states cannot prosecute women — or anyone who helps them — for going to another state to get the critical reproductive care that they need.”

“Elected officials in states like Tennessee and Texas and Alabama are trying to punish women for leaving their state for reproductive care, as well as anyone who helps them, including their doctors or even their employers,” Cortez Masto said. “Why? Because for these anti-choice politicians, this is about controlling women.”

Mississippi Republican Sen. Cindy Hyde-Smith objected to the unanimous consent request, saying that while members of the anti-abortion movement “most certainly do not oppose any individual’s freedom to travel across this great country,” they do have concerns the measure would hinder prosecution of crimes, like human trafficking.

Bill would ‘take us backward,” Budd says

Republicans blocked a second bill, sponsored by Murray, that would have blocked state governments from preventing, restricting, impeding, or disadvantaging health care providers from providing “reproductive health care services lawful in the state in which the services are to be provided.”

The bill was co-sponsored by 30 Democratic or independent senators.

“When I talk to abortion providers in Spokane, where they see a lot of patients fleeing restrictive abortion bans from states like Idaho, they are terrified that they could face a lawsuit that will threaten their practice and their livelihood, just for doing their jobs, just for providing care their patients need — care that is, once again, completely legal in my state,” Murray said. “We are talking about people who are following the law and simply want to provide care to their patients. This should be cut-and-dried.”

North Carolina GOP Sen. Ted Budd objected to the request, arguing the bill “would make it easier for unborn life to be ended.”

“The Supreme Court’s Dobbs decision brought renewed hope to Americans who believe in the sanctity of each and every life, including life in the womb,” Budd said. “But this bill would take us backward.”

Following Budd’s objection to passing the bill, Murray said his actions “made clear” that GOP lawmakers “have no problem whatsoever with politicians targeting doctors in states like mine, where abortion is legal.”

“I think that pretty much gives the game away,” Murray added.

Grant program

Democrats also tried to pass legislation from Wisconsin Democratic Sen. Tammy Baldwin that would have established a federal grant program to bolster the number of health care providers who receive “comprehensive training in abortion care.”

That bill had seven Democratic or independent co-sponsors in the Senate.

“For our top-ranked medical schools, a post-Roe reality sowed chaos as students and their instructors wondered how future doctors in our state would have access to the full slate of training necessary to safely practice obstetrics and gynecology,” Baldwin said.

Kansas Republican Sen. Roger Marshall, an OB-GYN, blocked the request, saying that the federal government “should not be spending taxpayer dollars to encourage medical students and clinicians to take life when their principal duty, their sacred oath, is to protect life and to do no harm from conception to natural death.”

Repeated attempts throughout 2024

Democrats sought to advance legislation on access to contraception and in vitro fertilization despite the 60-vote legislative filibuster earlier this year, and failed to get the necessary Republican support each time.

In early June, Democrats tried to advance legislation that would have protected “an individual’s ability to access contraceptives” and “a health care provider’s ability to provide contraceptives, contraception, and information related to contraception.”

A week later, Democrats tried again, this time with legislation that would have provided a right for people to access IVF and for doctors to provide that health care without the state or federal government “enacting harmful or unwarranted limitations or requirements.”

Collins and Murkowski were the only Republicans to vote to move the bills toward a final passage vote.

Alabama GOP Sen. Katie Britt attempted to pass an IVF access bill through the unanimous consent process in mid-June, but was unsuccessful.

That measure, which she co-sponsored with Texas Republican Sen. Ted Cruz, would have blocked a state from receiving Medicaid funding if it prevented IVF.

The legislation, which had three co-sponsors as of Wednesday, didn’t say what would happen to a state’s Medicaid funding if lawmakers or a state court defined life as starting at conception.

That’s what led IVF clinics in Alabama to temporarily shut down earlier this year after the state Supreme Court ruled that frozen embryos at IVF clinics constitute children under state law.

The Alabama state legislature has since provided civil and criminal protections for IVF clinics.

A federal rule seeks to add protections to a section of the Affordable Care Act that prevent health care providers who discriminate on the basis of gender identity or sexual orientation from receiving federal funding, including through Medicaid and the Children’s Health Insurance Program (photo illustration by Ross Williams/Georgia Recorder).

Missouri Attorney General Andrew Bailey is leading a coalition of seven states challenging a rule by the Biden administration that would preempt state restrictions on gender-affirming care. 

Filed in United States District Court for the Eastern District of Missouri on Wednesday, the states are seeking to block the regulation and prevent the federal government from enforcing similar mandates.

The rule seeks to add protections to a section of the Affordable Care Act that prevent health care providers who discriminate on the basis of gender identity or sexual orientation from receiving federal funding, including through Medicaid and the Children’s Health Insurance Program.

The rule was set to go into effect July 5, with some provisions beginning later. But another coalition of attorneys general succeeded in their petition to block its implementation just two days prior. The judge in that case cited the recent U.S. Supreme Court decision to overturn “Chevron Deference,” a precedent that gave regulatory authority to federal agencies when statute is unclear.

Bailey, along with attorneys general from Utah, North Dakota, South Dakota, Iowa, Idaho and Arkansas, argues that the rule conflicts with their states’ restrictions on gender-affirming care for minors. Each has varying restrictions on payments for gender-affirming treatment, with Missouri blocking payment for all treatments for medical transition through Medicaid and CHIP.

“… states will be unable to enforce these duly enacted laws and longstanding policies without coming into conflict with the rule,” the attorneys general wrote in the lawsuit.

The American College of Pediatricians joins the attorneys general as a plaintiff. The ACPeds is a group of 400 physicians and other health care professionals in 47 states with a history of anti-LGBTQ advocacy.

“ACPeds members categorically do not provide medical interventions or referrals for, and do not facilitate or speak in ways that affirm the legitimacy of, the practice of ‘gender transition,’” the attorneys general wrote.

The lawsuit alleges that the organization’s pediatricians would suffer “significant financial harm to lose eligibility to participate in federal healthcare programs such as Medicare, Medicaid, and CHIP.”

One pediatrician in Utah is quoted in the lawsuit saying he would not “self-censor his opinions on transition efforts if the rule goes into effect.”

Predicting his noncompliance with the rule, the Utah pediatrician “faces the prospect of no longer caring for his patients, being fired from his employment and being unable to practice medicine in most settings,” the attorneys general wrote.

The rule violates physicians’ freedom of assembly, the lawsuit states, “by coercing them to participate in facilities, programs, groups and other healthcare-related endeavors that are contrary to their views and that express messages with which they disagree.”

The lawsuit also says it “coerces ACPeds members’ speech.”

“By forcing ACPeds members to tell patients directly, on their walls, and on their websites that they do not discriminate on the basis of gender identity, the rule forces ACPeds members to speak falsely, and it forces ACPeds members to fatally undermine their communication of their own medical ethical standards,” it says.

Beyond questions of constitutionality, the attorneys general allege that the rule goes beyond congressional authorization.

The rule interprets gender identity as protected by both including gender dysphoria as a disability and interpreting sex discrimination to include gender identity. The attorneys general disagree with this application.

Key to the case will be the judge’s interpretation of the 2020 U.S. Supreme Court Case Bostock v. Clayton County, in which a majority of justices ruled that gender identity was protected under Title VII, which is on employment discrimination.

The rule leans on some courts’ interpretation that transfers the Bostock decision to Title IX and the Affordable Care Act, according to its publication in the Federal Register. But the attorneys general cite decisions from judges in red states that do not allow Bostock to apply outside of Title VII.

The Department of Health and Human Services, which is the defendant in the litigation, did not respond to a request for comment.

The St. Louis County office of Express Scripts, one of the nation's largest pharmacy benefit managers (Google Maps).

The federal trade watchdog on Tuesday released an interim report saying that sprawling health care conglomerates are driving out competition in the pharmacy sector and appear to be increasing prices in the process.

The interim report comes after the Federal Trade Commission in 2022 announced that it was undertaking a sweeping investigation of pharmacy middlemen known as pharmacy benefit managers, or PBMs.

Each of the largest three PBMs — CVS Caremark, Express Scripts and OptumRx — is part of a much-larger corporation that also owns a top-10 health insurer. They also own pharmacies, doctors offices and other links in the health chain, prompting the FTC to say they’re “vertically integrated.”

The corporations’ pharmacy benefit managers act as insurers’ representatives in pharmacy transactions. They decide which drugs are covered, they create pharmacy networks, and through an opaque system, they decide how much to reimburse pharmacies for the drugs they dispense.

The three biggest PBMs together are handling nearly 80% of prescription-drug transactions on behalf of insured Americans, the FTC report said. The largest six PBMs manage nearly 95% of all such prescriptions in the United States, it said.

“Amidst increasing vertical integration and concentration, these powerful middlemen may be profiting by inflating drug costs and squeezing Main Street pharmacies,” an executive summary of the report said.

The summary adds that the big PBMs “wield enormous power and influence over patients’ access to drugs and the prices they pay. This can have dire consequences for Americans, with nearly three in ten surveyed Americans reporting rationing or even skipping doses of their prescribed medicines due to high costs.”

For its part, and industry group representing PBMs said the businesses “have a proven track record of reducing prescription drug costs” and that they “recognize the vital role pharmacies play in creating access to prescription drugs for patients.”

JC Scott, president of the industry group, the Pharmaceutical Care Management Association, said the FTC had treated the PBM industry unfairly.

“Throughout this process, FTC leadership has shown that they have pre-determined conclusions that they want to advance irrespective of the facts or the data, and this report demonstrates an intention to follow through on their agenda regardless of the evidence,” Scott said in a statement.

But many independent and small-chain pharmacies dispute that PBMs have their interests at heart. U.S. Rep. Buddy Carter, a Republican from Georgia, is a pharmacist and has long called for the FTC to investigate the PBM industry.

“I’m proud that the FTC launched a bipartisan investigation into these shadowy middlemen, and its preliminary findings prove yet again that it’s time to bust up the PBM monopoly,” Carter said in a statement.

“We are losing more than one pharmacy per day in this country,” he said, “causing pharmacy deserts and taking the most accessible health care professionals in America out of people’s communities. I am calling on the FTC to promptly complete its investigation and begin enforcement actions if – and when – it uncovers illegal and anti-competitive PBM practices.”

Because they control access to so many patients, most pharmacies — especially small operations — feel they have little choice about signing the contracts the big PBMs offer them. For years, they’ve been complaining of declining reimbursements and seemingly arbitrary clawbacks from the huge PBMs. Many have been fleeing the business, saying they’re unable to cover their expenses.

Late last month, for example, news broke that Rite Aid would close hundreds of stores in Ohio and Michigan, with many more likely to close in the other 14 states where the bankrupt chain operates. The company tends to operate in smaller communities and the FTC says pharmacy closures in such communities are particularly harmful to patients.

“PBMs also exert substantial influence over independent pharmacies, who struggle to navigate contractual terms imposed by PBMs that they find confusing, unfair, arbitrary, and harmful to their businesses,” the agency said in a statement accompanying the interim report.

Between 2013 and 2022, about 10% of independent retail pharmacies in rural America closed.

“Closures of local pharmacies affect not only small business owners and their employees, but also their patients,” the agency said. “In some rural and medically underserved areas, local community pharmacies are the main healthcare option for Americans, who depend on them to get a flu shot, an EpiPen, or other lifesaving medicine.”

CVS operates the largest retail chain, so when its PBM decides how much to reimburse pharmacies for drugs, it’s using what the FTC called an “extraordinarily opaque” system to pay its own pharmacies and its competitors for the drugs they dispense.

Similarly, all three of the biggest PBMs operate mail-order pharmacies for expensive “specialty” drugs such as cancer medication. And they often encourage — if not require — patients to get their medicine from them. That has resulted in PBM-affiliated specialty pharmacies controlling 70% of sales in that class of drugs, the FTC report said.

Using mail-order for complex, quickly changing cancer drug regimens has led to horror stories among patients forced to get their drugs that way. Meanwhile, the FTC report uncovered evidence that in at least some instances, PBMs are paying their own companies’ pharmacies more for drugs in those transactions than they do their competitors.

“Our analyses also highlight examples of affiliated pharmacies receiving significantly higher reimbursement rates than those paid to unaffiliated pharmacies for two case study drugs,” it said. “These practices have allowed pharmacies affiliated with the three largest PBMs to retain levels of dispensing revenue well above estimated drug acquisition costs, resulting in nearly $1.6 billion of additional revenue on just two cancer drugs in under three years.”

Such practices have already prompted Ohio Attorney General Dave Yost to sue Express Scripts under the state’s antitrust law, the Valentine Act.

PCMA, the industry group, accused the FTC of using an unrepresentative sample in its analysis.

“Today’s interim FTC report falls far short of being a definitive, fact-based assessment of PBMs or the prescription drug market,” Scott, the group’s president said.

“Members of the commission themselves disagree with the content of the report and the decision to release it,” Scott continued. “This report is based on anecdotes and comments from anonymous sources and self-interested parties, and supported only by two cherry-picked case studies that are implied to be representative of the entire market. The report completely overlooks the volumes of data that demonstrate the value that PBMs provide to America’s health care system by reducing prescription drug costs and increasing access to medications.”

The FTC report also slammed arrangements under which the big PBM’s negotiate huge rebates and other discounts from drugmakers.

Because PBMs control access to so many patients, they have great leverage when they negotiate rebates and other discounts from makers of patented or “branded” drugs. The middlemen control the “formulary,” or list of covered drugs, and manufacturers have to cough up big if they want their products to be on it.

The system of granting huge, non-transparent discounts has already been shown to increase the “list” price of drugs. That’s the amount you would pay if you didn’t have insurance — and often the price on which your copayment or deductible is based.

The FTC said it came across another way the rebate system appears to be costing patients — by locking them out of cheaper generics that would work just as well.

“While this interim report principally focuses on the relationship between PBMs and pharmacies, we share evidence that PBMs and brand pharmaceutical manufacturers sometimes enter into agreements to exclude generic drugs and biosimilars from certain formularies in exchange for higher rebates from the manufacturer,” the report said. “These exclusionary rebates may cut off patient access to lower-cost medicines and warrant further scrutiny by the Commission, policymakers and industry stakeholders.”

FTC Chairwoman Lina Khan in March said that some of the PBMs weren’t cooperating with the investigation. Those problems apparently persist.

“The report notes that several of the PBMs that were issued orders have not been forthcoming and timely in their responses, and they still have not completed their required submissions, which has hindered the Commission’s ability to perform its statutory mission,” the agency said in a statement. “FTC staff have demanded that the companies finalize their productions required by the 6(b) orders promptly. If, however, any of the companies fail to fully comply with the 6(b) orders or engage in further delay tactics, the FTC can take them to district court to compel compliance.”

The story was originally published by the Ohio Capital Journal, a States Newsroom affiliate. 

Civil Courts Building in St. Louis (Rebecca Rivas/Missouri Independent)

A St. Louis judge on Friday determined Missouri Attorney General Andrew Bailey has no right to access unredacted private health information of transgender children treated at the Washington University Transgender Center at St. Louis Children’s Hospital.

St. Louis Circuit Court Judge Joseph Whyte ruled that Washington University does not have to provide the unredacted medical records sought by the attorney general’s office as part of his investigation into the clinic’s practices. 

Whyte found that the health information sought in Bailey’s demands is protected, and the data is not relevant to an investigation under the Missouri Merchandising Practices Act, which is the state’s consumer protection law. 

A third layer of protection for the information, the judge ruled, is the Health Information Portability and Accountability Act, or HIPAA, which prohibits the disclosure of personal health information without authorization.

Therapists, social workers face scrutiny in Missouri AG investigation of transgender care

The attorney general’s demands  “are not specific and limited in scope to the extent reasonably practicable in light of the purpose for which the information is sought, and respondent has not shown that de-identified information could not be reasonably used for the purpose for which it is sought,” Whyte wrote.

Bailey began looking into gender-affirming care at the Washington University Transgender Center in March 2023 after the center’s former case manager Jamie Reed provided an affidavit alleging rushed treatment.

The attorney general’s office sent civil investigative demands, which are similar to subpoenas, for health records to Washington University and other providers of gender-affirming care to minors, and four facilities filed suit against his requests for information.

Washington University, according to Friday’s ruling, responded to Bailey’s demand and gave him redacted records.

One of Bailey’s demands was for the university to, “identify all clients to whom you have provided your services. For each client, describe your services, the dates you provided your services, the amounts clients, their insurance or other third-party payors paid for these services and any contracts related to these services.”

The attorney general’s office also wanted “access to all electronic health records of clients,” according to the judgment.

Bailey said the redacted records were insufficient and asked the court to force Washington University to produce the documents in full. His reasoning for needing the information, though, was outside the bounds of the Missouri Merchandising Practices Act, Whyte determined.

Whyte recalled the attorney general arguing that he was looking into fraudulent billing of insurance and alleged that redactions removed communications about “red flag tracking” and patients who had discontinued treatment. That wasn’t a sufficient argument, Whyte ruled.

The judge wrote that the Missouri Merchandising Practices Act does not require “blind obedience to the attorney general’s civil investigative demands,” noting one section of the law that specifically exempts privileged material.

Bailey plans to appeal the order.

“There is no fight more important than the fight to make Missouri the safest state in the nation for children,” he said in a statement to The Independent. “My team remains undeterred in our quest to protect children. No stone will be left unturned in these investigations.”

Whyte is also presiding over a similar case involving demands for records from the St. Louis-based branch of Planned Parenthood, though in that case no records have been turned over to the attorney general at all.

Two other cases over Bailey’s access to medical records are playing out across the state in Jackson County, where Circuit Court Judge Joel Fahnestock ordered Kansas City’s Planned Parenthood organization and Children’s Mercy Hospital to produce requested documents

Planned Parenthood appealed in February, and the judge’s order is placed on hold until after appeal. Children’s Mercy did not appeal.

This article has been updated following comment from the attorney general’s office.

Wegovy and other injectable weight-loss medications have soared in popularity in the past two years. Supply issues and spotty insurance coverage have driven some patients to seek out compounded versions of the drug, which tend to be less expensive (Amanda Andrade-Rhoades/The Associated Press).

Anna Wysock’s “aha” moment arrived in an Ohio amusement park, as she got ready to ride a roller coaster with her 7-year-old son: The safety bar across her lap would only click into place once. The attendant told her it had to click twice, or she couldn’t ride. She was mortified.

“I had to do the walk of shame and get off the roller coaster and let my 7-year-old ride it with his cousin,” Wysock, an elementary school teacher and married mother of two, said of the 2022 incident. “I thought, ‘Anna, you’ve got to get yourself together.’”

Three months after the roller coaster incident, Wysock got a prescription for Mounjaro, an injectable diabetes drug that can be used for weight loss. Her insurance didn’t cover it, but a manufacturer’s coupon cut the cost to $25 per month. In six months, combined with diet and exercise changes, it helped her shed nearly 60 pounds.

Then the discount ended, raising the price to about $1,000 per month. Friends told her about a local clinic that offered cheaper, compounded versions of weight-loss drugs, and she got a prescription costing $150 per month. She began losing weight again.

To create a compounded drug, pharmacists reformulate the active ingredients in a commercial drug to customize it for an individual patient. Wysock was concerned about making the switch, fearing that the compounded version would cause unfamiliar side effects, “but it was worth it to me to try.”

Drugs prescribed for weight loss such as Mounjaro, Ozempic, Wegovy and Zepbound are popular, expensive, and in short supply. To meet the demand, many physicians, medical spas, IV infusion clinics, telehealth entrepreneurs and pharmacies are jumping on the opportunity to provide compounded versions of the weight-loss medications, which haven’t been on the market long enough to have generic equivalents.

State regulators are having trouble keeping up.

The U.S. Food and Drug Administration regulates commercial drugs, but the licensing and oversight of compounding pharmacies falls to states. States including Idaho and Tennessee have announced investigations into illegal dispensing by medical spas and other providers, while states such as California are looking to beef up their oversight.

“It’s not a normal situation that a blockbuster drug immediately goes on shortage and meets criteria for compounding pharmacies to compound it,” said Tenille Davis, an Arizona pharmacist and the chief advocacy officer for the Alliance of Pharmacy Compounding, an industry group representing compounding pharmacists.

“I don’t think we’ve ever seen anything like this.”

A cheaper alternative

Compounding pharmacies are allowed to make a medication that’s essentially a copy of a commercially available drug if its active ingredients are listed on the FDA’s drug shortage list. The active ingredient in weight-loss drugs such as Wegovy and Zepbound is either semaglutide or tirzepatide, and both are on the list.

“As the demand continues to grow, there continues to be a shortage of conventionally manufactured product, and compounding pharmacies are filling that need,” said Davis. “Compounding pharmacies have been able to step in and fill some of those gaps in the marketplace.”

Most states have similar compounding rules, though some states — including California and Texas — are stricter than others. Enforcement also varies.

In Mississippi, regulators have told doctors and other providers to stop prescribing compounded medications for weight loss — period. The state medical board has a rule that only medications that have been FDA-approved for weight loss can be prescribed for weight loss — meaning compounded drugs don’t qualify.

But many states and compounding pharmacies aren’t sure where the lines are. States including Kansas and New Jersey have had to issue statements clarifying their regulations. Last spring, North Carolina and West Virginia issued warnings that compounding weight-loss drugs wasn’t allowed — only to amend their statements after determining they had misinterpreted FDA guidance.

Federal law requires most U.S. compounding pharmacies to make medications for specific patients. They aren’t supposed to bulk manufacture medications unless they’re registered with the FDA as “outsourcing facilities,” which follow a stricter set of federal regulations.

But some states have found compounders breaking those rules.

In May, for example, Idaho’s licensing agency announced that regulators had discovered videos of health professionals filling syringes of weight-loss medications that weren’t compounded for specific patients, and then sending those syringes to patients, which is illegal under state law.

A compounding pharmacy in Nashville, Tennessee, that was producing tens of thousands of doses of compounded weight-loss medications shut down last year. It had been shipping its drugs nationwide. After state regulators inspected the facility and issued a disciplinary order requiring the company to make several changes before it could resume compounding, an executive died by suicide and the pharmacy’s owner chose to close.

And in Florida, a physician told the state pharmacy board he’d been approached by representatives from a multistate compounding pharmacy that wanted him to write prescriptions for their specific compounded semaglutide product — a form of prescription solicitation that’s likely illegal, Carter said.

Compounders generally don’t have to register with the FDA, and they aren’t required to report which drugs they’re compounding. That means there’s no way to know exactly how much semaglutide or tirzepatide they are dispensing, said Davis.

‘Like Whac-A-Mole’

To protect patients, the FDA enforces strict safety and quality requirements for drug manufacturers and for the small subset of compounding pharmacies registered as outsourcing facilities. The idea is that companies that are bulk manufacturing drugs need closer oversight than smaller compounding pharmacies that are merely customizing drugs for individual patients.

Compound pharmacies that bulk produce weight-loss drugs without FDA approval are doing so without that oversight.  And because compounding pharmacies aren’t required to report instances of patient harm involving their medications, problems may go undetected.

“It’s kind of like ‘Whac-A-Mole,’” said Al Carter, a pharmacist and executive director at the National Association of Boards of Pharmacy. He said state boards will only investigate when they receive a complaint.

“There are bad actors out there, purporting to be compounding pharmacies that are licensed in specific states or have the credentials to be able to compound when in actuality they don’t,” said Carter. “My understanding is most licensed, legitimate pharmacies aren’t compounding” weight-loss medications.

Most of the complaints that state regulators are hearing, he said, come from patients who tried to purchase their medications online. The National Association of Boards of Pharmacy recently released a report that found illegal online pharmacies — many operating outside the United States — sell substandard or fake weight-loss medications, or misrepresent the products they sell.

But even some domestic, legally operating clinics misrepresent the products they offer. Some clinics and online pharmacies advertise a “generic” form of semaglutide, even though the FDA hasn’t approved a generic form of semaglutide or tirzepatide.

Meanwhile, pharmaceutical giants Novo Nordisk and Eli Lilly have gone on the offensive, filing dozens of lawsuits in multiple states against medical spas, weight-loss clinics and pharmacies. Many of the suits allege the companies falsely marketed their compounded products as commercial medications.

An Eli Lilly spokesperson told Stateline in a statement that “Lilly will continue to pursue legal remedies against those who falsely claim their products are Mounjaro, Zepbound, or ‘FDA-approved’ tirzepatide, including certain med-spas, wellness centers, online retailers, and compounding pharmacies.”

Some states are focusing their investigations specifically on medical spas and IV infusion clinics that offer compounded weight-loss medications. The California State Board of Pharmacy recently discussed expanding its oversight of IV hydration clinics, noting that even when their drug products are from licensed compounding pharmacies, clinic staff may not be giving them to consumers legally.

And in Texas, some physicians are pushing for legislation to tighten state oversight of medical spas following the death last July of a woman who died after receiving an IV infusion treatment.

But ultimately the burden rests on patients to figure out whether the medications they’re taking were made by a licensed and reputable compounder.

For patients like Wysock, compounded versions of weight-loss medications have been life- changing. Wysock said her compounded tirzepatide has enabled her to continue to lose weight, to maintain a healthier lifestyle and to be present for her family and students.

“As a teacher you’re on your feet all day long, and then coming home to two kids, I was exhausted by the weekend,” she said. “I used to take naps every weekend. That was a ‘nonnegotiable.’ Now it’s not a necessity anymore.”

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

The U.S. Department of Agriculture has performed more than 17,000 tests for avian influenza on cattle, with 139 dairy herds throughout a dozen states (Getty Images).

WASHINGTON — Public health officials have diagnosed a Colorado farm worker with the country’s fourth human case of highly pathogenic avian influenza, the Centers for Disease Control and Prevention and the state’s department of health reported Wednesday.

The Colorado case, the state’s first this year related to spread from dairy cattle to humans, was reported after an adult man working on a farm in the northeast region of the state experienced conjunctivitis or pink eye.

The unidentified man, who has since recovered, was being monitored by public health officials after dairy cattle on the farm he worked on tested positive for H5N1, or bird flu.

Dr. Rachel Herlihy, an epidemiologist with the Colorado Department of Public Health and Environment, wrote in a statement announcing the diagnosis that the “risk to most people remains low.”

“Avian flu viruses are currently spreading among animals, but they are not adapted to spread from person to person,” Herlihy wrote in the statement. “Right now, the most important thing to know is that people who have regular exposure to infected animals are at increased risk of infection and should take precautions when they have contact with sick animals.”

Nationwide, the U.S. Department of Agriculture has reported bird flu in 139 dairy herds throughout a dozen states, including Colorado, Idaho, Iowa, Kansas, Michigan, Minnesota, New Mexico, North Carolina, Ohio, South Dakota, Texas and Wyoming.

In Colorado, there have been 27 dairy herds where at least one cow has tested positive for H5N1 since the outbreak began, according to data from the USDA.

The other three human cases reported this year include two dairy farm workers in Michigan and one in Texas. Two of the cases were pink eye, while one of the Michigan patients experienced mild respiratory symptoms.

The Colorado Department of Public Health and Environment wrote in its announcement Wednesday that 2022 was the last time a person within the state was diagnosed with bird flu. That time it was the result of infected poultry.

Bird flu continues to spread in the country’s poultry flocks as well, though that industry has had much more time to adjust and get its workers used to wearing personal protective equipment than dairy farmers have.

More than 97 million poultry throughout 48 states have tested positive for H5N1 since this outbreak began in January 2022, according to reports from the Centers for Disease Control and Prevention.

Unlike dairy cows, which generally recover from bird flu, poultry flocks are culled after a diagnosis, making response and recovery to H5N1 vastly different.

The USDA began a voluntary pilot program for dairy farmers in late June that gives them the option to have their herd’s bulk milk tanks tested. The program is designed to make it easier for farmers to transport their cows across state lines.

The U.S. Department of Health and Human Services announced Tuesday that it would direct $176 million to Moderna to develop a vaccine that would inoculate people against the virus.

(Al Drago/Getty Images)

A landmark Supreme Court decision that reins in federal agencies’ authority is expected to hold dramatic consequences for the nation’s health care system, calling into question government rules on anything from consumer protections for patients to drug safety to nursing home care.

The June 28 decision overturns a 1984 precedent that said courts should give deference to federal agencies in legal challenges over their regulatory or scientific decisions. Instead of giving priority to agencies, courts will now exercise their own independent judgment about what Congress intended when drafting a particular law.

The ruling will likely have seismic ramifications for health policy. A flood of litigation — with plaintiffs like small businesses, drugmakers, and hospitals challenging regulations they say aren’t specified in the law — could leave the country with a patchwork of disparate health regulations varying by location.

Agencies such as the FDA are likely to be far more cautious in drafting regulations, Congress is expected to take more time fleshing out legislation to avoid legal challenges, and judges will be more apt to overrule current and future regulations.

Health policy leaders say patients, providers, and health systems should brace for more uncertainty and less stability in the health care system. Even routine government functions such as deciding the rate to pay doctors for treating Medicare beneficiaries could become embroiled in long legal battles that disrupt patient care or strain providers to adapt.

Groups that oppose a regulation could search for and secure partisan judges to roll back agency decision-making, said Andrew Twinamatsiko, director of the Health Policy and the Law Initiative at Georgetown University’s O’Neill Institute. One example could be challenges to the FDA’s approval of a medication used in abortions, which survived a Supreme Court challenge this term on a technicality.

“Judges will be more emboldened to second-guess agencies,” he said. “It’s going to open agencies up to attacks.”

U.S. Supreme Court flips precedent that empowered federal agencies

Regulations are effectively the technical instructions for laws written by Congress. Federal agency staffers with knowledge related to a law — say, in drugs that treat rare diseases or health care for seniors — decide how to translate Congress’ words into action with input from industry, advocates, and the public.

Up until now, when agencies issued a regulation, a single rule typically applied nationwide. Following the high court ruling, however, lawsuits filed in more than one jurisdiction could result in contradictory rulings and regulatory requirements — meaning health care policies for patients, providers, or insurers could differ greatly from one area to another.

One circuit may uphold a regulation from the Centers for Disease Control and Prevention, for example, while other circuits may take different views.

“You could have eight or nine of 11 different views of the courts,” said William Buzbee, a professor at Georgetown Law.

A court in one circuit could issue a nationwide injunction to enforce its interpretation while another circuit disagrees, said Maura Monaghan, a partner at Debevoise & Plimpton. Few cases are taken up by the U.S. Supreme Court, which could leave clashing directives in place for many years.

In the immediate future, health policy leaders say agencies should brace for more litigation over controversial initiatives. A requirement that most Affordable Care Act health plans cover preventive services, for example, is already being litigated. Multiple challenges to the mandate could mean different coverage requirements for preventive care depending on where a consumer lives.

Drugmakers have sued to try to stop the Biden administration from implementing a federal law that forces makers of the most expensive drugs to negotiate prices with Medicare — a key cog in President Joe Biden’s effort to lower drug prices and control health care costs.

Parts of the health care industry may take on reimbursement rates for doctors that are set by the Centers for Medicare & Medicaid Services because those specific rates aren’t written into law. The agency issues rules updating payment rates in Medicare, a health insurance program for people 65 or older and younger people with disabilities. Groups representing doctors and hospitals regularly flock to Washington, D.C., to lobby against trims to their payment rates.

And providers, including those backed by deep-pocketed investors, have sued to block federal surprise-billing legislation. The No Surprises Act, which passed in 2020 and took effect for most people in 2022, aims to protect patients from unexpected, out-of-network medical bills, especially in emergencies. The high court’s ruling is expected to spur more litigation over its implementation.

“This really is going to create a tectonic change in the administrative regulatory landscape,” Twinamatsiko said. “The approach since 1984 has created stability. When the FDA or CDC adopt regulations, they know those regulations will be respected. That has been taken back.”

Industry groups, including the American Hospital Association and AHIP, an insurers’ trade group, declined to comment.

Agencies such as the FDA that take advantage of their regulatory authority to make specific decisions, such as the granting of exclusive marketing rights upon approval of a drug, will be vulnerable. The reason: Many of their decisions require discretion as opposed to being explicitly defined by federal law, said Joseph Ross, a professor of medicine and public health at Yale School of Medicine.

“The legislation that guides much of the work in the health space, such as FDA and CMS, is not prescriptive,” he said.

In fact, FDA Commissioner Robert Califf said in an episode of the “Healthcare Unfiltered” podcast last year that he was “very worried” about the disruption from judges overruling his agency’s scientific decisions.

The high court’s ruling will be especially significant for the nation’s federal health agencies because their regulations are often complex, creating the opportunity for more pitched legal battles.

Challenges that may not have succeeded in courts because of the deference to agencies could now find more favorable outcomes.

“A whole host of existing regulations could be vulnerable,” said Larry Levitt, executive vice president for health policy at KFF.

Other consequences are possible. Congress may attempt to flesh out more details when drafting legislation to avoid challenges — an approach that may increase partisan standoffs and slow down an already glacial pace in passing legislation, Levitt said.

Agencies are expected to be far more cautious in writing regulations to be sure they don’t go beyond the contours of the law.

The Supreme Court’s 6-3 decision overturned Chevron U.S.A. v. Natural Resources Defense Council, which held that courts should generally back a federal agency’s statutory interpretation as long as it was reasonable. Republicans have largely praised the new ruling as necessary for ensuring agencies don’t overstep their authority, while Democrats said in the aftermath of the decision that it amounts to a judicial power grab.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

The University of Kansas Health System, which has its primary location in Kansas City, Kansas, has entered a partnership Liberty Hospital in Missouri. News of the deal last fall sparked discontent among some state lawmakers. (Allison Kite/Missouri Independent)

Despite resistance from lawmakers in both Kansas and Missouri, Liberty Hospital has officially joined the University of Kansas Health System, executives announced Monday.

Leaders of the health system announced the completion of the merger Monday in a short video Monday alongside the CEO of Liberty Hospital, located in the Kansas City suburbs north of the Missouri River.

Liberty’s leadership began looking in May 2023 to partner with another health system to help the hospital meet growing demand. It announced in October that it had chosen the University of Kansas. 

Raghu Adiga — who served as Liberty Hospital’s CEO and now is CEO of the Liberty market for KU — said the hospital’s board of trustees evaluated more than 30 potential partners. He said he’s “more than convinced” merging with the Kansas hospital system was the right decision.

“We share a commitment to putting patients first,” Adiga said. “We prioritize our people and believe in providing high quality care close to home. To have a strong community, we need to have strong healthcare. We believe this relationship not only strengthens Liberty Hospital, but the Liberty community and the entire Northland.” 

Missouri lawmakers debate blocking University of Kansas deal with Liberty hospital

Tammy Peterman, president of KU Health’s Kansas City Division, said about 35% of the health system’s patients currently come from Missouri, and KU already has clinics in the state. 

“We knew eventually we would need a way to care for more patients in Missouri and the Northland to keep care close to home,” Peterman said. “…So today is a big milestone for us as well: our very first hospital in Missouri.” 

Health system leaders did not take questions from journalists following the press conference. Asked about the terms of the deal, a spokeswoman for KU said in an email that the health system’s leaders are “celebrating the next couple of days” and were not available to comment.

KU and Liberty’s merger was met with disdain from some lawmakers in both Kansas and Missouri. Former-Missouri Sen. Greg Razer, a Kansas City Democrat, pushed legislation earlier this year to block the deal, calling it “mind boggling” and saying the idea of a Kansas health system owning a Missouri hospital felt “terribly wrong.” 

But supporters of the deal argued Liberty needed a larger hospital partner to be able to grow and make investments in its facilities. A Liberty board member told lawmakers this spring that if the hospital didn’t merge with KU, it could be purchased by a for-profit chain and stop offering some of its services, becoming “little bit more than a triage center.” 

Bob Page, president and CEO of the University of Kansas Health System, said it’s “incredibly difficult in health care today to remain a completely independent hospital” like Liberty.

“They found a new path forward to ensure they could continue to deliver high quality care in the Northland for generations to come,” Page said. “By becoming part of this health system, they will be able to offer some of the most advanced treatments and expertise anywhere in the country.”

Razer’s legislation made it out of a Senate committee but never received a floor vote. 

Missouri Attorney General Andrew Bailey also opposed the merger, writing in a letter to Senate leadership in January that the deal was illegal unless the Missouri General Assembly signed off on it. An attorney for Liberty said, however, that the deal was structured to comply with state laws. 

Kansas Senate President Ty Masterson, a Republican from Andover, expressed frustration about the merger in a committee meeting in November, saying struggling hospitals in Kansas could have benefitted from a partnership with KU.

And Kansas Sen. J.R. Claeys, a Salina Republican, filed legislation that would have required KU get permission from the Kansas Legislature before entering a deal that involves acquiring, building, repairing or improving property outside of Kansas. The bill never got a hearing.

In the meantime, the systems were working toward a finalized deal that is expected to include investment in Liberty’s facilities. 

Peterman said over the coming months, KU leadership will learn more about how Liberty operates and how it can be best integrated into the health system. 

“This includes everything from inpatient and ambulatory care to supply chain and branding,” she said. “Ultimately, we want to ensure we are one health system offering a seamless and consistent patient experience.”

At CSL Plasma on Broadway Boulevard in midtown Kansas City, willing plasma donors line up on a recent day before the center's 6 a.m. opening (Suzanne King/The Beacon).

Michael Mullen donates blood plasma every Tuesday and Thursday. He has for 12 years.

The money it brings in — a little over $100 a week — augments what he makes as a chef. He’s come to rely on it.

“It helps supplement bill paying,” he said recently, smoking a cigarette outside the Biomat USA donation center on East 63rd Street where he’d just spent an hour and a half in the donation chair. “If I didn’t have it, I don’t know. I don’t know what would happen.”

Kelcey Gordon is out of work and said he’d struggle without the money he makes donating twice a week. Standing outside the same for-profit plasma donation center, one of 11 in the Kansas City area, he said he is grateful for the extra cash it represents.

In the $35 billion plasma pharmaceutical industry, Mullen, Gordon and some 3 million other U.S. adults supply the raw material the industry counts on.

The plasma they deposit every week is tested, processed and separated into protein parts that become medicine to treat rare, chronic conditions like immune deficiencies, autoimmune diseases and bleeding disorders.

Their plasma, collected at a storefront that shares a shopping center with a Thriftway and lies just a block east of Cash America Pawn, will end up in medicines sold for hundreds or thousands of dollars a dose. It will likely treat patients on the other side of the world.

Thanks to regulations that make the United States one of the few countries to let companies pay for plasma, and because people here can donate as often as twice a week, the U.S. supplies about 70% of the world’s plasma.

“This is the world basket of plasma,” said Peter Jaworski, a Georgetown University professor who studies the plasma economy.

The industry — with the enthusiastic backing of organizations that advocate for people suffering from the diseases that plasma therapies treat — says the system works. If people weren’t paid to donate, they argue demand could not be met. That would mean thousands of people would die or be unable to live normal lives.

The plasma centers, most of them owned and operated by pharmaceutical companies based overseas, say their business models also inject money into local communities.

Donation centers employ phlebotomists, security guards and screeners. And the payments made to donors — which vary based on how often someone donates and, in some cases, how much a donor weighs — go back into the local economy.

But doctors and public health experts caution that no one really knows what frequent plasma donations over many years could mean for donors’ health.

And they worry that poor people provide a bulk of U.S. donations at plasma centers. Plasma centers tend to set up in disadvantaged neighborhoods and rely on incentive programs designed to make donors give again and again.

Plasma centers push people to give as often as possible, but they don’t disclose the unknown risks of frequently extracting plasma from their blood for many years.

“People perceive it as a better alternative than high-cost loans that lead to debt,” said Emily A. Gallagher, an assistant professor of finance at the University of Colorado. She co-authored a study about the intersection between plasma donors and payday loan customers.

“Without knowing the longer-term health consequences,” she said, “it’s analogous to a loan against your future house with an unknown interest rate.”

Therapies from donated plasma

The blood running through your veins includes red blood cells, white blood cells, platelets and plasma. Plasma — a yellow-tinged liquid — accounts for more than half of your blood.

It is 90% water, but also contains proteins vital to living a normal life. When someone has plasma that lacks  — or is short on — certain proteins, they end up with rare and chronic diseases. Medicines made from healthy human plasma treat those diseases by supplementing the lacking plasma.

For someone with primary immune deficiency, a condition in which a person’s immune system doesn’t function properly, it takes 130 donations to cover a year’s worth of treatment. For a person with alpha-1 antitrypsin deficiency, a potentially fatal disease that can lead to organ damage, that number jumps to 900 donations a year. And for someone with hemophilia, a blood clotting disorder, it takes 1,200 donations of plasma to make a year’s worth of medicine.

Scientists have known about blood circulation since 1628, and blood transfusions began almost that long ago. In 1665, a British doctor figured out how to keep a dog alive by transfusing blood from other dogs.

At the beginning of the 20th century, scientists began to figure out that different people had different blood types. And by World War II the value of blood plasma was well understood.

In 1940, researchers developed a process to break plasma down into individual components to treat patients. That’s essentially what happens to plasma donated today.

Wild west of plasma collection

Donated plasma goes through a process known as fractionation, which separates plasma into various protein parts. Once it is tested and cleaned — a process that can take up to a year — those proteins are pooled with other donors’ plasma and made into therapies.

Plasma therapies for patients on the receiving end are considered extremely safe today. Tests designed to find plasma tainted by disease are highly effective. And plasma pharmaceutical makers won’t use plasma until a donor has given at least twice and the donor has passed a health screening. In addition, plasma is treated to kill any lingering virus before it is used in medicine.

But in the 1980s, before it was understood that viruses like HIV could be transmitted through blood, plasma transfusions proved deadly.

In the United States, 63% of hemophiliacs contracted HIV after receiving plasma from infected donors. Others contracted hepatitis B and hepatitis C, diseases that are also transmitted through blood.

After those “wild west days of plasma collection,” Jaworski said, the industry underwent drastic changes. That included pharmaceutical companies taking over independent donation centers. In recent years, those centers have multiplied.

Pharmaceutical companies operate a combined 1,000 collection centers in the United States. That’s compared to 300 in 2005.

The business of taking human plasma and turning it into medicine is worth about $35 billion this year. And that could nearly double by 2032, according to Fortune Business Insights, a market research firm.

Growing demand for plasma donations

Kansas City-area donation centers are all owned directly by the companies that make the plasma-derived drugs.

They include the Biomat on 63rd Street, owned by Grifols S.A., a Spanish company. Other Kansas City donation centers are owned by CSL Ltd., based in Australia, Takeda Pharmaceuticals from Japan and Octapharma Plasma, out of Switzerland.

Experts say the influx of new donation centers in recent years follows growing demand for plasma therapies. That’s because scientists are figuring out that more diseases can benefit from plasma medicines. During the COVID pandemic, plasma transfusions from previously infected donors were tried as a treatment, but its effectiveness isn’t understood because scientific testing was lacking.

Demand for plasma therapies is also up because more people are being diagnosed with diseases that could benefit from them.

For example, improved newborn screenings mean more people know they have primary immune deficiency, diseases that affect an estimated 500,000 people. But according to the Immune Deficiency Foundation, “tens of thousands” of others remain undiagnosed.

Only the United States, Germany, the Czech Republic and a few other countries allow payments for plasma donations. The countries that restrict payments have to rely on imports, primarily from the U.S. There is no synthetic alternative to human plasma.

That’s why Jaworski wants more countries to allow paid plasma.

“There isn’t a single country in the world that collects enough plasma to meet demand unless they compensate donors,” he said. “The most important moral mission for a system of blood and plasma collection is to meet the needs of patients.”

By that standard, he said, the American system is unquestionably succeeding.

“America not only collects enough for its own citizens,” he said, “it also collects enough for the rest of the world.”

Is it safe to donate plasma twice a week?

Through a process known as plasmapheresis, the plasma collected at for-profit centers is taken out of a donor’s arm as whole blood, pumped into a machine that separates out plasma and returns red blood cells and other components of blood to the donor.

That process, known as source plasma collection, is regulated by the U.S. Food and Drug Administration and also overseen by the countries that import the plasma. Donors spend about 90 minutes in the donation chair.

Nonprofit blood centers like the Community Blood Center of Greater Kansas City collect plasma through whole blood donations. Plasma is separated out once blood has been donated. But that process yields much less plasma.

Nonprofit blood banks don’t pay for donations. For one thing, hospitals won’t accept blood from a donor who has been compensated. And the World Health Organization advises against paying for donations. It’s considered risky because donors who give blood because they need money could be more likely to misrepresent their health history — essentially hiding the likelihood that they’re carrying blood-borne infections.

Because plasma used in pharmaceuticals is so thoroughly processed, the risk posed by paid donations is lower. Jaworski said it’s proved to be extraordinarily safe for 30 years. He argues that objections to paid plasma donations are unrealistic when so many people rely on plasma therapies.

He compared paying people for their plasma to hiring firefighters rather than relying on volunteers. The payment doesn’t diminish the good act, he said.

“At some point, you get too many fires and you have to pay people to put out the fires,” he said. “We hit that tipping point (for plasma) more than 20 years ago.”

People who rely on the therapies created from paid-for plasma are actively campaigning to be sure paid donations continue.

The Immune Deficiency Foundation has a program meant to recruit more paid donors. “Your work will encourage donors to continue donating and, in turn, encourage their friends and family to donate plasma as well,” the organization’s web page says.

But while plasma-derived therapies are critical for the patients relying on them to live a normal life, some doctors worry about what plasma donation could do to donors.

Plasma collection centers advise donors to drink lots of water, get sleep and have a healthy meal before donating. In the near term, donors are told to be prepared for certain temporary side effects like dehydration, dizziness and fatigue.

On its webpage, CSL Plasma also warns about the possibility that donating frequently for a long period of time can deplete immunoglobulin levels, which can lower a person’s ability to fight off infections.

What is the downside to donating plasma?

Dr. Morey A. Blinder, a hematologist at Washington University, said that’s definitely something frequent plasma donors should worry about. Long-term studies, looking at people who donate plasma twice a week, year after year, simply haven’t been done, he said.

“You’re depleting a person’s proteins in their bloodstream,” he said. “And it’s hard to know what the effect of that is.”

Proteins regenerate, he said, so in the short term, people can keep up. But it’s unclear what happens over time.

And while the plasma collection centers monitor donors’ health, their incentive isn’t to limit donations. It’s to collect as much plasma as possible.

“There are financial incentives to these donors to stay on schedule and keep donating,” Blinder said.

Many doctors would feel more comfortable, he said, if that pressure were reduced. Blinder also would like to see more frequent checks of donors’ blood levels, and a weekly, rather than twice weekly, donation limit.

“People in this field would say that would be an advantage,” he said.

Blinder also questions whether the pharmaceutical companies are paying donors fairly. Donors take home around $50 per donation, but the medicine it’s eventually turned into can cost $200 a gram, perhaps $16,000 per treatment dose, depending on the illness.

“We don’t have a good sense of the margins they earn on the plasma,” said Gallagher, the University of Colorado professor.

Right or wrong, the paid plasma business has become a reasonably big thread in the country’s social safety net. Gallagher found that people tend to donate plasma so they can get extra money and avoid taking out high-interest loans to make ends meet. Donors range from college students to single parents to low-wage earners who just need extra cash.

BioLife Plasma Services is promising new donors “up to $800.” And CSL Plasma advertises new donors “over $700 your first month.”

Whether or not donors are getting a fair payment, selling plasma is tempting a growing number of Americans. And, like Mullen and Gordon, they’re relying on the extra cash.

That’s why most mornings, before CSL Plasma’s donation center at 37th and Broadway opens for business at 6 a.m., a line of ready donors is already waiting outside.

This article first appeared on Beacon: Kansas City and is republished here under a Creative Commons license.

A protester at a Planned Parenthood Great Northwest rally in Boise, Idaho, holds up a sign about the EMTALA case on April 21, 2024 (Otto Kitsinger/Idaho Capital Sun).

As expected after the court said it inadvertently uploaded the opinion prematurely on Wednesday, the U.S. Supreme Court issued a decision Thursday remanding a case about emergency abortions in Idaho back to the Ninth Circuit Court of Appeals for now.

The decision was 6-3, with conservative Justices Samuel Alito, Neil Gorsuch and Clarence Thomas dissenting. It was issued “per curiam,” meaning there is no lead author of the overall opinion.

The justices affirming the decision wrote that they determined the court took the case too early in the process. It granted the request to hear the case in January before the Ninth Circuit Court of Appeals could hold its own hearing on an injunction that blocked enforcement of the law against emergency room physicians who might need to perform an abortion to prevent a pregnant patient from experiencing significant health effects from infection or other conditions.

The government argued Idaho could not enforce its criminal abortion ban in emergency rooms because it would violate a federal law known as the Emergency Medical Treatment and Labor Act, or EMTALA, which requires Medicare-funded hospitals to treat patients who come to an emergency room regardless of their ability to pay.

When justices agreed to hear the case, the court also dropped the injunction, leaving doctors in Idaho open to prosecution under its criminal abortion ban, which carries penalties of jail time, fines and the loss of a medical license. Idaho’s civil law also allows immediate and extended family members to sue the doctors for up to $20,000 over an abortion procedure.

Idaho’s ban contains only an exception to save the pregnant patient’s life, not to prevent detrimental health outcomes, including the loss of future fertility, which is a risk with severe infection or bleeding. Without further clarity written into the law, doctors have said they can’t confidently assess when to safely intervene to save someone’s life.

Rather than take the chance, high-risk obstetric specialists have airlifted patients to a facility out of state that can freely perform the procedure before it’s too late. In 2023, the state’s largest hospital system said at their facilities such transfers happened once, but occurred six times between January and April, when the injunction was lifted.

Justice Amy Coney Barrett, who is typically conservative in her rulings, said the court’s decisions to hear the case and drop the injunction were premised on the belief that Idaho would suffer “irreparable harm” under the injunction and that the cases were ready for the court’s immediate determination.

She wrote that the briefings and oral argument in April shed more light on the case, and made it clear that conscience objections were covered under EMTALA and other concerns about an interpretation that would include emergency mental health concerns did not apply.

“I am now convinced that these cases are no longer appropriate for early resolution,” Barrett wrote.

Dr. Caitlin Gustafson, president of a group of Idaho physicians who have spoken out against the ban and submitted a brief to the court in the case, said the decision is not the end of her coalition’s work.

“We are relieved by the Supreme Court’s decision,” Gustafson said. “However, this ruling addresses only a small part of the ever-increasing barriers across the health care landscape. The coalition remains committed to advocating for comprehensive policy updates to fill the gaps in healthcare access created by Idaho’s restrictive laws, which jeopardize patient safety. We will not relent until private healthcare decisions are once again at the discretion of patients and their physicians, free from political interference.”

Ahead of the decision, more than 6,000 doctors from around the country also appealed to the court to protect ER physicians, along with medical professionals in Idaho and advocacy organizations.

The case now returns to the Ninth Circuit to resume the process, but it could ultimately return to the Supreme Court at a later date.

The Cole County Courthouse in Jefferson City (Annelise Hanshaw/Missouri Independent)

Attorneys representing transgender minors and health care providers squabbled with the Missouri Attorney General’s Office Wednesday over thousands of documents both sides say are being wrongfully withheld.

At its core, the case seeks to determine whether the state’s ban on gender-affirming care for minors is lawful. The lawsuit was filed by the families of three transgender minors, Southampton Healthcare, two of Southampton’s providers and two national advocacy organizations, saying the ban could have “extremely serious, negative health consequences” for transgender youth.

The attorney general filed a counterclaim alleging Southampton Healthcare, which provides gender-affirming care, did not fully disclose risks when treating transgender youth.

A trial is scheduled for late September, and attorneys are in the process of deposing witnesses. The deadline to send responsive documents to the other party passed, but both plaintiffs and defendants were unhappy with how much the other side has willingly turned over. 

Therapists, social workers face scrutiny in Missouri AG investigation of transgender care

Wright County Circuit Court Judge Craig Carter, who is stepping into Cole County Circuit Court for this case, said it would take time to rule on each exception the parties found to requests for discovery.

Jim Lawrence, an attorney for the plaintiffs, argued that the state has withheld documents citing exceptions not backed by state law.

Lawrence told the judge the parties would “be here until next week” if he were to explain every document he is requesting. He displayed a powerpoint with a chart of the objections from the attorney general’s office and the corresponding evidentiary requests.

Peter Donahue, assistant attorney general for special litigation, said the state went through a “burdensome” process of reviewing 100,000 documents that matched search terms in investigatory requests and spent $25,000 taking the time to narrow the lot to what is relevant and not deemed protected — which ended up being 2.6% of those files.

“If the state reviewed 100,000 (documents) and only 2,600 are relevant… That is an impossible fact to digest,” Lawrence said. “That doesn’t pass the smell test.”

Included in the state’s objections were documents protected by “gubernatorial privilege,” Lawrence said. This impacted almost half of the requests for production issued to the office of Gov. Mike Parson.

Gubernatorial privilege, Lawrence argued, doesn’t exist. He said there isn’t legal precedent in Missouri for it.

The idea of an executive privilege was discussed during the attorney general’s investigation of former Gov. Eric Greitens, with many dismissing the excuse as illegitimate.

“They are asking you to be the first court in the state of Missouri to declare gubernatorial privilege,” Lawrence told the judge.

Donahue said he hadn’t seen the privilege successfully invoked in Missouri, but it was “widely recognized across the nation.”

“We are just talking about communications between the governor and his close circle,” Donahue said. “This is not a unique concept in the gubernatorial process.”

Carter asked what types of documents have been withheld from discovery under gubernatorial privilege. Lawrence listed off a handful of examples, including “policies and procedures related to enforcement of the act.”

“Even if (gubernatorial privilege) does exist, it wouldn’t apply to all that,” he said.

Donahue said the objection was an “add-on privilege” for some of the documents, where another exception would have already protected the information from disclosure.

Lawrence tossed an arm up at the admission, then folding his arms and furrowing his brow.

“His argument really goes to why we are here today,” he said. “If you are asserting a privilege and withholding information based upon a privilege, you have to put that.”

It is written in the privilege log, Donahue said. A privilege log is a file that describes the documents withheld and the privileges asserted to protect them.

Lawrence also took issue with claims of attorney-client privilege that protected Jamie Reed, a witness in the case and whistleblower following her work at the Washington University Transgender Center at St. Louis Children’s Hospital. Reed’s affidavit alleging quick “medicalization” of transgender minors launched the attorney general’s investigation of gender-affirming care and was a main talking point when lawmakers discussed a ban for minors.

The attorney general isn’t Reed’s lawyer, Lawrence said, so his office shouldn’t argue attorney-client privilege for documents related to her.

Plaintiffs subpoenaed Reed separately and received a letter she sent to the attorney general. That letter should have also been sent by the attorney general’s office responsive to the investigative requests, but plaintiffs didn’t get it, Lawrence said.

Other exceptions include external communications allegedly withheld as work product and many documents sealed under investigative privilege.

Lawrence said they did not receive the responses the public gave to a tip line the attorney general opened to report complaints about gender-affirming care, but that information was compiled for outside sources. Indeed, St. Louis Public Radio requested the responses in a Sunshine Request and received the compilation a year later.

Donahue also argued Southampton was withholding documents. He said he received informational pamphlets from Southampton but wanted medical records of four or five patients that received gender-affirming care as minors.

Planned Parenthood vows to fight Missouri AG push for transgender youth medical records

The judge questioned why he needed these particular documents.

“These documents are relevant to our counterclaim that plaintiffs have been inaccurate about the types of harm that can come from these treatments,” Donahue said. 

He argued gender-affirming care providers weren’t always truthful — a claim patients have disputed when their care is questioned.

“It essentially amounts to snake-oil salesmanship, if true,” he said.

He wanted to get access to records showing what doctors have discussed with patients and letters of support from mental-health professionals, which he said sometimes have “irregularities.”

Complaints from the attorney general’s office about these letters have led to the investigations of 57 health professionals, putting their licenses at risk. As of early May, 16 cases were open in the probe by the Department of Professional Registration.

Jason Orr, another attorney representing plaintiffs, said the state may ask Southampton’s physicians questions but can’t ask for patients’ private records.

“Southampton does not have the ability to waive their doctor-patient privilege, and in fact, they are required to exercise it on their behalf,” he said.

There are currently four cases open between healthcare providers and the attorney general where providers are fighting requests to hand over medical records.

Southampton’s patients are not the plaintiffs in the case at hand, Orr said.

Plaintiffs PFLAG and GLMA, two advocacy organizations, have not been complying with requests for documents, Donahue argued.

He said he hasn’t received anything from the two organizations, despite the deadline already passing.

Orr said the request led to 20,000 documents that attorneys are “working in good faith” to narrow down and deliver. He hoped for it to be ready by the end of the week, complaining that the request was sent one month before the deadline.

“This was an issue that was created in part by defendants’ timing,” he said.

At the start of the hearing Wednesday, Solicitor General Josh Divine mentioned a federal case that may change their proceedings.

The U.S. Supreme Court agreed Monday to hear a case on Tennessee’s ban on gender-affirming care for transgender minors.

There are additional claims in the case before Carter, Orr said.

Carter said to keep him updated if the case will be affected.

“We’re going to keep marching on until we hear something different,” he said.

Half of U.S. states have a restriction on gender-affirming care for minors, with litigation blocking some states’ bans.

Holstein milking cows at an Idaho dairy on July 20, 2012 (Kirsten Strough/USDA)

WASHINGTON — The U.S. Department of Agriculture announced Tuesday that four states will launch voluntary pilot programs in the days ahead to test bulk milk tanks on dairy farms for bird flu — a move that’s aimed at making it easier for farmers to ship herds across state lines and for public health officials to track spread of the virus.

Kansas, Nebraska, New Mexico and Texas will be in the first round of voluntary participation, with other states likely to follow, officials said on a call with reporters.

“This list of participating states is just the beginning,” said Eric Deeble, the acting senior advisor for H5N1 response at USDA.

“We are in close conversation with about a dozen other states who are very interested in participating as well,” Deeble said. “But it was important for us to get these four states going so that other states could watch how the program works and gain additional confidence.”

The launch of the pilot program, he said, is “an important step forward” for efforts to reduce the spread of bird flu, also known as H5N1, as well as for expanding understanding of the virus.

Farmers who voluntarily enter the program will be able to move their herds across state lines without additional testing after bulk milk tanks or similar representative samples test negative for H5N1 for three consecutive weeks.

“Producers must also comply with continued regular weekly monitoring and testing of their herd for H5N1, but that process can happen with very little effort on the part of the producer, using routine bulk milk samples,” Deeble said.

126 cases of bird flu confirmed