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This Nonprofit Health System Cuts Off Patients With Medical Debt

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This Nonprofit Health System Cuts Off Patients With Medical Debt

Many hospitals in the United States use aggressive tactics to collect medical debt. They flood local courts with collections lawsuits. They garnish patients’ wages. They seize their tax refunds.

But a wealthy nonprofit health system in the Midwest is among those taking things a step further: withholding care from patients who have unpaid medical bills.

Allina Health System, which runs more than 100 hospitals and clinics in Minnesota and Wisconsin and brings in $4 billion a year in revenue, sometimes rejects patients who are deep in debt, according to internal documents and interviews with doctors, nurses and patients.

Although Allina’s hospitals will treat anyone in emergency rooms, other services can be cut off for indebted patients, including children and those with chronic illnesses like diabetes and depression. Patients aren’t allowed back until they pay off their debt entirely.

Nonprofit hospitals like Allina get enormous tax breaks in exchange for providing care for the poorest people in their communities. But a New York Times investigation last year found that over the past several decades, nonprofits have fallen short of their charitable missions, with few consequences.

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Allina has an explicit policy for cutting off patients who owe money for services they received at the health system’s 90 clinics. A 12-page document reviewed by The Times instructs Allina’s staff on how to cancel appointments for patients with at least $4,500 of unpaid debt. The policy walks through how to lock their electronic health records so that staffers cannot schedule future appointments.

“These are the poorest patients who have the most severe medical problems,” said Matt Hoffman, an Allina primary care doctor in Vadnais Heights, Minn. “These are the patients that need our care the most.”

Allina Health said it has a robust financial assistance program that in an average year helps over 12,000 of its 1.9 million patients with medical bills. The hospital system cuts off patients only if they have racked up at least $1,500 of unpaid debt three separate times. It contacts them by phone and with repeated letters that include information about applying for financial help, said Conny Bergerson, a hospital spokeswoman.

“Allina Health’s goal is, and will always be, to have zero patients go without services for financial reasons,” Ms. Bergerson said. She said that cutting off services was “rare” but declined to provide information on how often it happens.

Allina suspended its policy of cutting off patients in March 2020, at the onset of the coronavirus pandemic, before reinstating it in April 2021.

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An estimated 100 million Americans have medical debts. Their bills make up about half of all outstanding debt in the country.

About 20 percent of hospitals nationwide have debt-collection policies that allow them to cancel care, according to an investigation last year by KFF Health News. Many of those are nonprofits. The government does not track how often hospitals withhold care.

Under federal law, hospitals are required to treat everyone who comes to the emergency room, regardless of their ability to pay. But the law — called the Emergency Medical Treatment and Labor Act — is silent on how health systems should treat patients who need other kinds of lifesaving care, like those with aggressive cancers or diabetes.

In 2020, thanks to its nonprofit status, Allina avoided roughly $266 million in state, local and federal taxes, according to the Lown Institute, a think tank that studies health care.

In exchange, the Internal Revenue Service requires Allina and thousands of other nonprofit hospital systems to benefit their local communities, including by providing free or reduced-cost care to patients with low incomes.

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But the federal rules do not dictate how poor a patient needs to be to qualify for free care. In 2020, Allina spent less than half of 1 percent of its expenses on charity care, well below the nationwide average of about 2 percent for nonprofit hospitals, according to an analysis of hospital financial filings by Ge Bai, a professor at the Johns Hopkins Bloomberg School of Public Health.

Allina is one of Minnesota’s largest health systems, having largely grown through acquisitions. Since 2013, its annual profits have ranged from $30 million to $380 million. Last year was the first in the past decade when it lost money, largely owing to investment losses.

The financial success has paid dividends. Allina’s president earned $3.5 million in 2021, the most recent year for which data is available. The health system recently built a $12 million conference center.

Yet Allina sometimes plays hardball with patients. Doctors have become accustomed to seeing messages in the electronic medical record notifying them that a patient “will no longer be eligible to receive care” because of “unpaid medical balances.”

Dr. Rita Raverty, a primary care doctor who works at an Allina clinic, said the notifications were alarming because they meant she could not provide continuous care for some of her patients facing a number of health risks.

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“Nobody wins when patients can’t get preventive care,” Dr. Raverty said. “It creates worse disease outcomes when you’re not catching things early.”

Doctors and patients described being unable to complete medical forms that children needed to enroll in day care or show proof of vaccination for school.

Serena Gragert, who worked as a scheduler at an Allina clinic in Minneapolis until 2021, said the computer system simply wouldn’t let her book future appointments for some patients with outstanding balances.

Ms. Gragert and other Allina employees said some of the patients who were kicked out had incomes low enough to qualify for Medicaid, the federal-state insurance program for poor people. That also means those patients would be eligible for free care under Allina’s own financial assistance policy — something many patients are unaware exists when they seek treatment.

Ms. Bergerson, the Allina spokeswoman, did not dispute that but said the health system goes “to tremendous lengths to assist patients with their financial obligations for medical care.”

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Allina employees said the policy has forced them to ration care.

Beth Gunhus, a pediatric nurse practitioner, recalled a case in which a mother brought in her three children. One had scabies, an intensely itchy skin condition caused by mites burrowing into the body. She wanted to follow best practices and treat the entire family, who were sharing one bed in a single room they rented, to ensure it didn’t spread further. But she could write a prescription for only two of the children. The third’s account was locked because of unpaid bills.

“There are so many better ways of saving money than what we’re doing,” Ms. Gunhus said.

Allina says the policy applies only to debts related to care provided by its clinics, not its hospitals. But patients said in interviews that they got cut off after falling into debt for services they received at Allina’s hospitals.

Because Allina is the dominant health system in some rural parts of Minnesota, getting kicked out can leave patients with few options.

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Jennifer Blaido lives in Isanti, a small town outside Minneapolis, and Allina owns the only hospital there. Ms. Blaido, a mechanic, said she racked up nearly $200,000 in bills from a two-week stay at Allina’s Mercy Hospital in 2009 for complications from pneumonia, along with several visits to the emergency department for asthma flare-ups. Ms. Blaido, a mother of four, said most of the hospital stay was not covered by her health insurance and she was unable to scrounge together enough money to make a dent in the debt.

Last year, Ms. Blaido had a cancer scare and said she couldn’t get an appointment with a doctor at Mercy Hospital. She had to drive more than an hour to get examined at a health system unconnected to Allina.

Allina does not make this policy explicit to patients. It is not mentioned in the health system’s list of “frequently asked questions” about billing practices. In at least one case, Allina has denied that it even existed.

In a lawsuit filed last year in state court in Minnesota, Allina sued a couple, Jordan and JoLynda Anderson, for nearly $10,000 in unpaid medical bills.

In court filings, the couple described how Allina canceled Ms. Anderson’s appointments and told her that she could not book new ones until she had set up three separate payment plans — one with the health system and two with its debt collectors.

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Even after setting up those payment plans, which totaled $580 a month, the canceled appointments were never restored. Allina allows patients to come back only after they have paid the entire debt.

Ms. Anderson recalls being devastated about losing her visit to an endocrinologist that specialized in a chronic condition she has. She had already been waiting four months for the appointment, and was unable to get a new one.

“It felt like I was being punished, and the punishment was you get to stay ill,” she said.

Ms. Bergerson declined to comment on these cases, citing patient privacy.

When the Andersons asked in court for a copy of Allina’s policy of barring patients with unpaid bills, the hospital’s lawyers responded: “Allina does not have a written policy regarding the canceling of services or termination of scheduled and/or physician referral services or appointments for unpaid debts.”

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In fact, Allina’s policy, which was created in 2006, instructs employees on how to do exactly that. Among other things, it tells staff to “cancel any future appointments the patient has scheduled at any clinic.”

It does provide a few ways for patients to continue being seen despite their unpaid bills. One is by getting approved for a loan through the hospital. Another is by filing for bankruptcy.

Susan C. Beachy contributed research.

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California communities are banning syringe programs. Now the state is fighting back in court

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California communities are banning syringe programs. Now the state is fighting back in court

As Indiana officials struggled to contain an outbreak of HIV among people who injected drugs, then-Gov. Mike Pence reluctantly followed the urgings of public health officials and cleared the way for an overwhelmed county to hand out clean syringes.

Pence was far from enthusiastic about launching the program in Scott County, but after it rolled out in 2015, the percentage of injection drug users there who said they shared needles dropped from 74% to 22%. Within a few years, the number of new HIV infections plummeted by 96% and new cases of hepatitis C fell by 76%.

The Sierra Harm Reduction Coalition wanted to keep those same diseases in check in California. The tiny nonprofit got approval from the state to deliver syringes in El Dorado County to prevent the spread of life-threatening illnesses.

Yet when the program was discussed at a December meeting of the county’s Board of Supervisors, the success story in Indiana held little sway. Faced with complaints about discarded needles and overdose deaths, the supervisors voted to prohibit syringe programs in the county’s unincorporated areas.

“These programs may work in other parts of California and throughout the United States, although I have my doubts,” Sheriff Jeff Leikauf said at the meeting. “El Dorado County does not want or need these types of programs.”

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El Dorado is among a growing number of California communities that have banned syringe programs, testing the state’s power and political will to defend them as a public health strategy. It is part of a broader pushback against “harm reduction” — the practical philosophy of trying to reduce the negative effects of drug use — as overdose deaths have soared.

Now California is fighting back. In a recently filed lawsuit, the Department of Public Health argued that local ordinances prohibiting syringe programs in El Dorado County were preempted by state law, making them unenforceable.

The state is seeking a court order telling El Dorado County and the city of Placerville, its county seat, to stop enforcing their bans and allow syringe programs to resume.

An El Dorado County spokesperson said Monday that the county does not comment on pending legal issues. Its district attorney, however, said he was outraged to learn of the lawsuit, saying that state leaders were “seeking to impose the normalization of hardcore drug use.”

“Don’t come into our county and double down on your failed policy,” El Dorado County Dist. Atty. Vern Pierson said in a statement. “Allowing addicts to use fentanyl and other hardcore drugs is exactly what has caused other California counties to experience a death rate that is out of control and getting worse.”

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Mona Ebrahimi, the city attorney for Placerville, said the city had put a 45-day temporary moratorium in place “to study the ongoing effects of syringe service programs in the city.”

“The city wants to protect the health, safety and welfare of its residents,” Ebrahimi said.

The California Department of Public Health has long endorsed handing out sterile syringes as a proven way to prevent dangerous infections from running rampant when people share contaminated syringes. Researchers have linked syringe programs with a roughly 50% reduction in HIV and hepatitis C.

“It sounds crazy: ‘Wait, you want to give out the tools to people to do this thing that we all agree is a bad idea?’” said Peter Davidson, a medical sociologist at UC San Diego. But it works, said Davidson, who called the programs “probably the best studied public health intervention of the last 70 years.”

Public health officials also see them as a crucial way to reach people who use drugs and link them to addiction and overdose-prevention services. In Seattle, for instance, researchers found that injection drug users who started going to a needle exchange were five times more likely to enter drug treatment than those who never went.

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Signs direct visitors to the syringe-exchange program at the Austin Community Outreach Center in Austin, Ind., in 2015. The program was set up to curb an outbreak of HIV among people who injected drugs.

(Darron Cummings / Associated Press)

And in California, harm reduction groups have been particularly effective in getting Narcan — a nasal spray that can reverse opioid overdoses — into the hands of people who need it.

It’s “hugely important to reduce overdose in the community, and these are the programs that do that,” said Barrot Lambdin, a health policy fellow at RTI International who studies the implementation of health interventions.

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Yet leaders in some cities and counties have strenuously rejected the health benefits of syringe programs.

In El Dorado County, local leaders asserted that the efforts of the Sierra Harm Reduction Coalition had not “meaningfully reduced” HIV or hepatitis C cases since its syringe program began four years ago and said the free needles were ramping up the risk of deadly overdoses, which they argued were a bigger threat.

Street scene shows trees with fall colors, cars and old buildings

The El Dorado County Courthouse in Placerville, Calif.

(Max Whittaker / For The Times)

Alessandra Ross, a harm reduction expert at the California Department of Public Health, disputed such arguments in a letter to county officials. Ross pointed out that in just one year, the coalition handed out more than 2,200 doses of medication to reverse opioid overdoses, saving at least 421 lives. Without the group’s efforts, she wrote, “El Dorado County could have potentially lost more than ten times as many people to overdose.”

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Under state law, the California Department of Public Health has the authority to approve syringe programs anywhere that deadly or disabling infections might spread through used needles, “notwithstanding any other law” that might say otherwise.

The agency argued that the “significant state and public interest in curtailing the spread of HIV, hepatitis, and other bloodborne infections extends to every jurisdiction in the state, especially since Californians travel freely throughout the state.”

After El Dorado County prohibited syringe services in unincorporated areas, the state public health department adjusted its authorization for the Sierra Harm Reduction Coalition program, limiting its operations to Placerville. In the court filing, the agency said it made the change out of concern for the coalition’s staff and volunteers, who could be at risk of arrest if they provided syringes in the unincorporated areas.

The nonprofit said when it stopped providing syringes outside of Placerville city limits, roughly 40% of its clients were cut off. In February, Placerville city officials passed their own urgency ordinance banning syringe programs for 45 days, exempting needle provision at health facilities.

Ebrahimi, its city attorney, said officials took that step “after CDPH concentrated their use by authorizing them only in Placerville and nowhere else in the county.”

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The Sierra Harm Reduction Coalition stopped providing syringes in Placerville as well, according to the state lawsuit. The coalition did not respond Monday to requests for comment on the suit.

El Dorado County and Placerville are not alone: A wave of local bans went into effect last year in Placer County after a harm reduction group from Sacramento sought state approval to hand out clean syringes. The county’s sheriff and its probation chief said in a letter to the state that the syringe program proposed by Safer Alternatives thru Networking and Education, or SANE, would “promote the use of addicting drugs” and lead to more “dirty needles discarded recklessly in our parks.”

The Placer County Board of Supervisors voted unanimously to ban syringe programs in its unincorporated areas. Cities including Auburn, Loomis and Rocklin banned them too.

“We are the ones who should make these kinds of decisions,” then-Mayor Alice Dowdin Calvillo said at a September meeting of the Auburn City Council, “and not allow the state to just bully us.”

Public health researchers stress that studies have found that free needle programs do not increase crime or drug use, or worsen syringe litter. Yet as much of Placer County became a no-go zone, SANE withdrew its application for a syringe program there.

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“Our political processes are not well set up for us to make reasoned, scientifically sound judgments about public health,” said Ricky Bluthenthal, a USC sociologist whose research has documented the effectiveness of syringe programs. It doesn’t help that “the populations at risk are often marginalized or not politically active.”

Our political processes are not well set up for us to make reasoned, scientifically sound judgments about public health.

— Ricky Bluthenthal, a USC sociologist who studies syringe programs

The California Department of Public Health declined to address whether it planned to challenge local bans on syringe programs elsewhere in the state, saying it “cannot comment on active litigation strategy.”

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Syringe programs have long faced public skepticism: In a 2017 survey, only 39% of U.S. adults said they supported legalizing them in their communities.

Experts say the programs have faced increasing jeopardy as public concern wanes about the threat of HIV and frustration swells over other problems like soaring numbers of overdose deaths and the spread of homeless encampments. Even in Indiana’s Scott County, local leaders voted three years ago to shutter its needle exchange.

Clashes are also arising because programs are making moves into new parts of California, bolstered in some cases by state funding. California officials also have taken steps to help syringe programs overcome local opposition, including exempting them from review under the California Environmental Quality Act.

“It’s not surprising that cities and counties are motivated to protect the public health and safety of their residents through whatever tools they have at their disposal,” said attorney David J. Terrazas, who represented a group that successfully sued to overturn state approval of a syringe program in Santa Cruz County.

In that case, a state appeals court ruled last year that the California Department of Public Health conducted an insufficient review of a program run by the Harm Reduction Coalition of Santa Cruz County. The department didn’t do enough to consult with law enforcement agencies in the area, among other shortcomings, the court said.

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Although the state health department had considered some comments from law enforcement, “it never engaged with them directly about their concerns,” the appeals court concluded. Internal records showed department staff had decided not to respond to some of their comments and called one police chief an “imbecile.”

Terrazas said local officials are best poised to know what works for their communities. But Denise Elerick, founder of the Harm Reduction Coalition of Santa Cruz County, argued it made no sense for law enforcement to hold sway in public health decisions.

“We wouldn’t consult with them on what to do about COVID,” Elerick said.

A bag is filled with boxes of Narcan nasal spray for distribution to people living on the street in Los Angeles.

A bag is filled with boxes of Narcan nasal spray, one of several harm-reduction supplies distributed to people living on the street in Los Angeles.

(Francine Orr / Los Angeles Times)

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Weeks after the court ruling, the state health department rolled back its approval for a syringe program in Orange County that would have been run by the Santa Ana-based Harm Reduction Institute, saying it wanted to consult more with local officials.

The decision was celebrated by city leaders in Santa Ana, who had banned syringe programs in 2020 and sharply opposed efforts to restart one. At a recent meeting, interim city manager Tom Hatch said a previous program was “an epic failure” that left its downtown littered with used syringes.

Orange County is currently the most populous county in the state without any syringe services programs — to the alarm of health researchers who found that syringe reuse increased after a local program was shut down.

The Santa Cruz court ruling was also invoked by the Santa Monica City Council, which directed city officials to investigate how Los Angeles County came to approve a program run by the Venice Family Clinic. That program sends outreach workers into Santa Monica parks once a week to offer clean syringes, Narcan and other supplies and connect people with healthcare, including for addiction.

A woman hands out Narcan to a man at Tongva Park in Santa Monica

Devon O’Malley, left, a harm reduction case manager with the Venice Family Clinic, hands out Narcan to Ken Newark at Tongva Park in Santa Monica.

(Mel Melcon / Los Angeles Times)

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Critics want the program to relocate indoors, which they say would better protect parkgoers from discarded syringes. In addition, “if someone has to walk inside, there’s a chance for counselors to suggest strongly that it’s time for them to get off the drugs,” said Santa Monica Mayor Phil Brock, who wants the city to formally express its opposition to the program. “We can’t just facilitate their demise.”

Last month, a group called the Santa Monica Coalition filed suit to get L.A. County to halt the program it approved, saying it should instead be in a government building.

But Venice Family Clinic staffers said unhoused people can be reluctant to leave behind their belongings to go elsewhere. Even offering services out of a van reduced participation, said Arron Barba, director of the clinic’s Common Ground program.

“Bringing the service directly to the people is what we know works,” Barba said.

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Opinion: How measles reemerged as a threat in California and elsewhere

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Opinion: How measles reemerged as a threat in California and elsewhere

The measles virus is resurging in the U.S. despite the long-standing availability of a vaccine that provides nearly life-long immunity. In the past few weeks, hundreds of people were exposed to a child with the virus in a Northern California healthcare facility; our state is one of 17 jurisdictions with reported measles cases in 2024, higher than seen in recent years.

Measles is an extremely transmissible pathogen: On average, one infected person infects 12 to 18 unvaccinated people. The airborne virus can linger in floating aerosols long after someone has left a room, and the common symptoms, which include rash, a high fever, watery eyes, cough and a runny nose, typically take a week or two to appear.

Infections can also cause immune amnesia, in which your immune system becomes better at fighting measles and worse at fighting other infections you were previously protected against. In rare cases it also leads to death, more often in children than adults, from respiratory or neurological complications, including a type of brain swelling in young children that can appear years after the initial measles infection.

Before the measles vaccine was introduced and licensed in 1963, the Centers for Disease Control and Prevention cites an annual average of 549,000 cases (with likely millions more going unreported), 48,000 hospitalizations, nearly 500 deaths and 1,000 people with chronic disability. By 2000, thanks to vaccination, measles was declared eliminated in the U.S. But because of cases from people arriving here from other countries, combined with pockets of low vaccination, we are seeing outbreaks among unvaccinated people.

Policy can worsen the issue. Last month in Florida, following an outbreak at an elementary school, the state’s surgeon general left the decision to parents whether to send their children to school, citing high levels of community immunity as the rationale for not following the usual protocols. That cavalier response risked a much worse outbreak. A more standard response would have called for unvaccinated students and staff to be vaccinated and quarantine for 21 days (the time frame in which the disease could develop).

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It might be tempting to Californians to dismiss this as a Florida problem. But our state has a measles time bomb on our hands. Ideally communities should hit at least 95% vaccination to achieve herd immunity. But a recent nationwide survey found that Southern California alone has 350 schools falling short of the desired vaccination threshold, meaning a single measles case in these schools could easily become an outbreak among the unvaccinated.

Misinformation around the measles vaccine has been an issue for years. A debunked but influential 1998 research paper in the Lancet, a British medical journal, suggested a link between the vaccine, which babies can receive starting at the age of 12 months, and autism. The paper was retracted in 2010 (and the authors were later reported to have committed fraud). But measles vaccine rates dropped in England throughout the early 2000s.

In California, a 2014 outbreak at Disneyland was connected to more than 140 cases in North America, with declining vaccination rates one contributing factor. A recent systematic review of the reasons why parents reject measles vaccination for their children found fear of autism the most cited concern. Those who were hesitant more frequently cited the internet and social media as information sources on vaccines than those who were not hesitant.

In recent years hesitancy has grown as misinformation about the COVID vaccine has made some parents doubtful of routine inoculations. Vaccination exemptions during the 2022-23 school year reached the highest level ever reported in the U.S., increasing in 40 states and Washington, D.C., and 10 states reaching exemption rates of above 5%. According to the CDC, the 93.1% vaccination rate among eligible children puts about 250,000 kindergarten students at risk for measles.

Encouragingly, we’ve seen in our own state that vaccine hesitancy can be reversed. Marin County had among the lowest measles vaccination rates in the state in 2011 and now has coverage close to 99% among children entering school. State contact tracing efforts that were strengthened during COVID-19, including the California Connected program, have been useful to track the contacts of measles cases.

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But as the recent scares remind us, we still aren’t where we need to be with vaccination. Following the Disneyland outbreak, in 2015 California passed a law to remove the “personal belief” exemption from required childhood vaccines, meaning people must provide a medical reason to decline it. The law broadened the criteria for medical exemptions, which increased the year after it passed. Although the state tightened up medical exemptions with a new law in 2019, with the pandemic disrupting routine vaccinations and increasing homeschooling, the percentage of kindergarteners not up to date on vaccinations went up by 2021.

Vaccine exemption laws vary widely across the U.S., with some states allowing only medical exemptions, some also allowing religious exemptions and others permitting philosophical exemptions too. And outbreaks from one state can spill over across borders quickly.

That means decisions by Florida’s public health department, and vaccine hesitancy anywhere, can affect us all. California has to close the gap for communities that are not well-protected against measles.

Abraar Karan is an infectious disease doctor and researcher at Stanford University, where Julie Parsonnet is a professor of infectious diseases and of epidemiology and population health.

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Video: SpaceX Launches Starship for Third Time

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Video: SpaceX Launches Starship for Third Time

new video loaded: SpaceX Launches Starship for Third Time

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SpaceX Launches Starship for Third Time

The rocket, a version of which will eventually carry NASA astronauts to the moon, traveled almost halfway around the Earth before it was lost as it re-entered the atmosphere.

“Five, four, three, two, three, one.” “This point, we’ve already passed through Max-Q, maximum dynamic pressure. And passing supersonic, so we’re now moving faster than the speed of sound. Getting those on-board views from the ship cameras. Boosters now making its way back, seeing six engines ignited on ship. Kate, we got a Starship on its way to space and a booster on the way back to the Gulf.” “Oh, man. I need a moment to pick my jaw up from the floor because these views are just stunning.”

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