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What the Supreme Court’s abortion pill case could mean for California

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What the Supreme Court’s abortion pill case could mean for California

Lee had just been dumped when she found out she was pregnant.

With no car, no job and no support, the 23-year-old — who asked that her last name be withheld for medical privacy — ended up at the virtual clinic Hey Jane, where she was quickly assessed and prescribed abortion medication.

Four months later, thousands of Californians in a similar situation have been holding their breath as the U.S. Supreme Court weighed a case that could rewrite the rules of care in more than two-thirds of U.S. abortions, limiting access to a popular drug even in states where it remains legal.

The justices voiced clear doubts about a lower court’s decision to overrule the Food and Drug Administration and restrict mifepristone — the first in a two-drug protocol that now accounts for 63% of all legal abortions in the United States — signaling they are unlikely to restore byzantine rules for prescribing the medication.

“Do we have to also entertain your argument that no one else … in America should have this drug in order to protect your clients?” Justice Ketanji Brown Jackson said in a pointed exchange later echoed by her frequent rival Justice Neil M. Gorsuch.

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But advocates in California say even if the current rules are left in place, the case represents a growing threat to reproductive rights in “sanctuary” states — particularly as legal challenges target telehealth, which has risen to account for 16% of U.S. abortions since 2021.

These numbers do not include the roughly 6,000 abortions estimated to take place outside the formal medical system each month, the overwhelming majority of them likewise induced by a combination of mifepristone and misoprostol procured through the mail, according to a study this week in the medical journal JAMA.

“I’m concerned that people don’t realize how important telehealth is — it’s a major pillar in the abortion care landscape,” said professor Ushma Upadhyay of UC San Francisco, a reproductive healthcare expert. “People don’t understand how important it could become in the future.”

‘Bewildering, surprising and unexpected’

The court’s ruling on mifepristone is not expected until June. The reason the stakes are high is that unlike the decision in Dobbs vs. Jackson Women’s Health Organization, which overturned Roe vs. Wade in 2022, a Supreme Court ruling to restrict the drug would roll back a series of important changes to the way it is prescribed and dispensed nationwide.

Care that can currently be delivered by a nurse-midwife via a brief video call or online questionnaire would revert to a time-consuming and costly series of clinic visits with a physician. Medication abortion could be offered for only 49 days from the start of a patient’s last period, instead of up to 10 weeks as it is today. Those changes would also bar mifepristone prescriptions through telehealth, leaving some to rely on a less effective regimen with more unpleasant side effects.

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Telehealth is the only viable option for patients who can’t take a sick day, find a babysitter — data from the Centers for Disease Control and Prevention show the lion’s share of abortion patients are already mothers — or catch a ride to a clinic that may be hours away on public transit, experts say.

“I’ve had patients tell me, ‘I’ve got a job that won’t let me take time off. I’ve got kids and no child care,’” said Dr. Michele Gomez of the MYA Network, a consortium of virtual providers, who has served many patients with Medi-Cal. “Lots of people talk to me while they’re at work. I’ve had so many people [take appointments] with their kids crawling all over them.”

Women who have relied on the medication say it felt like the most convenient — and safest — option.

“I knew the clinic locations, but actually getting there was hard,” Lee said of her abortion. “It all felt so scary, on top of having to be in the situation.”

Gomez said that in years past doctors were required to watch patients take the pill. Eliminating those and other rules helped propel medication abortion from the margins of care to the heart of reproductive rights within the last decade, the Bay Area provider and others said.

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“I can send [pills] out by mail any time it works for me,” she said.

The changes also paved the way for clinicians in California and five other states to prescribe and mail abortion medication to patients in jurisdictions where it’s been banned, under so-called shield laws.

“Abortion care via mail is now the most viable form of access for most of the country,” said Kiki Freedman, co-founder and chief executive of Hey Jane, an abortion telehealth startup. “Any change to the way mifepristone is prescribed is an attack on access, period.”

Indeed, a growing number of experts believe the rise of telehealth could explain why abortions jumped in the wake of the Dobbs decision, even as 21 states have partially or completely outlawed the procedure.

“This is bewildering, surprising and unexpected — we expected the numbers to drop,” said Upadhyay. “There’s a lot of unmet need being met through telehealth.”

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‘Half the patients I see are sitting in their car’

The meteoric rise of medication abortion is part of the reason antiabortion activists have gone to such pains to get rid of it, many say.

“Telehealth abortion is worrisome to that side because they know that it is safe and it is effective and people can end pregnancies on their own,” said Michele Goodwin, a law professor at UC Irvine and an expert on reproductive justice. “That’s threatening to them.”

Medication abortion using mifepriestone was already cheaper, faster and easier to access than vacuum aspiration and other in-clinic procedures when telehealth became available under emergency pandemic rules in 2020.

But it became radically more accessible and less expensive in 2021, as virtual providers including Hey Jane, Abortion on Demand and 145 Abortion Telemedicine established themselves alongside brick-and-mortar clinics under the FDA’s new guidance.

And more clinicians felt called to offer it in 2022, as state bans pushed abortion seekers to neighboring states, stretching wait times at in-person clinics in Colorado, Illinois and Kansas, where an in-clinic appointment can take weeks to secure.

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“Even before the Dobbs decision, I asked myself, what can I do?” said Dr. Stephanie Colantonio, a Los Angeles-based pediatrician who began providing care in 2021. “It was really meaningful to me that I would be able to offer this to people.”

California has also moved to make care more accessible, though barriers remain. Medi-Cal covers about half of all abortions in the state — almost the same as the proportion of births it pays for — but billing for telehealth is still novel, and few providers can do it.

“California only recently updated the law to cover telehealth for abortion last year,” said Upadhyay. “For most [Medi-Cal] patients, they have to decide, do I want free abortion or do I want to pay and get telehealth?”

That decision is often fraught.

“We see a lot of patients on lunch breaks,” said Leah Coplon, a nurse-midwife and director of clinical operations at Abortion on Demand. “I feel like half the patients I see are sitting in their car.”

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‘In the comfort of my own home’

Seeking pills through the mail can also be the only physically accessible option for disabled abortion-seekers.

“The disability community is very concerned about this, because this could result in complete denials of care,” said Jillian MacLeod, reproductive justice legal fellow at the Disability Rights Education & Defense Fund, which filed a brief in support of telehealth abortion.

Still others say telehealth simply feels safer to them.

“I wanted to be able to do it in the comfort of my own home,” said Charlie Ann Max, a Los Angeles model who took the pills earlier this year. “It felt the most safe.”

With mifepristone under threat, some providers are looking at alternatives that would keep telehealth available to those who need it most. Many say that would mean prescribing only the second drug in the protocol, misoprostol, which is used to induce labor as well as for pregnancy termination.

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“That would be the backup,” said Dr. Jayaram Brindala of 145 Telehealth. “It’s not ideal clinically, but still a good option for people who are in the first 13 weeks.”

Gomez agreed. “It’s very effective, but it’s not what I would recommend for my sister or my best friend or my daughter,” the doctor said.

Last year, Gov. Gavin Newsom announced California would stockpile the drug to maintain an emergency supply.

“Those who oppose abortion access have made it clear that they will not stop seeking new ways to roll back access and abortion rights across the country,” state Atty. Gen. Rob Bonta said.

His Department of Justice will use “every tool” at its disposal to keep California a haven for reproductive healthcare, he said.

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“No matter what happens in the mifepristone case in the Supreme Court, it’s not going to be the end of our fight,” Bonta said.

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Opinion: Most older Americans who need hearing aids don't use them. Here's how to change that

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Opinion: Most older Americans who need hearing aids don't use them. Here's how to change that

Having depended on hearing aids for nearly three decades, I’m astounded by the lack of Medicare coverage for devices that can solve a problem afflicting tens of millions of older Americans.

Nearly two-thirds of Americans over age 70 have some degree of hearing loss, and over half of those 75 and older experience impairment serious enough to be considered disabling. But most don’t wear hearing aids.

Because the legislation that created Medicare nearly 60 years ago specifically excluded hearing aids, those who rely on the program’s traditional coverage must pay for them out of pocket. That expense is among the chief barriers to wider use of the devices.

Age-related hearing loss impedes basic communication and the relationships that depend on it. Expanded access to hearing aids could therefore do no less than enable more older Americans to establish and maintain the social connections that are essential to a meaningful life.

Hearing loss is like an invisible, muffling curtain that falls in front of anyone speaking. Asking people to repeat themselves can yield irritated and hurtful responses. And it’s hopeless to ask a soft-spoken person to speak up. Sometimes it’s easier just to nod and smile.

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Many older people I know choose to avoid social gatherings altogether because they can’t hear well. Without hearing aids, I’d stay home too.

Hearing loss can harm one’s health in other ways. For example, I’ve written about the need for a comprehensive approach to reducing cancer risk at older ages, including preventive services such as colorectal cancer screening. But these services rely on conversations between patients and their healthcare providers. An older patient’s ability to hear and understand such conversations shouldn’t be taken for granted or ignored.

The Food and Drug Administration did improve access to hearing aids by making some of them available without a prescription in 2022, but the over-the-counter devices are inadequate for serious hearing loss like mine. My private health insurance, meanwhile, started covering hearing aids a few years ago, providing up to $2,500 for them every five years. One hearing aid alone can cost that much or more, however.

Despite its limitations, my private coverage for hearing aids is better than nothing, which is what traditional Medicare provides.

Hearing loss is more common among lower-income people and those without advanced education. The toll from noisy workplaces compounds age-related hearing loss for some. One analysis found that most Americans with a serious hearing disability can’t afford the typical price of hearing aids.

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Many of the older adults who can’t come up with these significant out-of-pocket expenses spent their working years in low-wage jobs that our country depends on. Denying them treatment for their hearing loss is a lousy way to treat people who gave years of service to our society.

Although some older adults with hearing loss won’t benefit from hearing aids, Medicare coverage for the devices might encourage more beneficiaries to get their hearing tested so they can get the treatment that’s right for them. And while Medicare coverage alone won’t address the stigma some people associate with hearing aids, the availability of newer, more comfortable and less obvious technology might win over some refuseniks.

Legislation reintroduced with bipartisan support last year would finally correct this glaring gap in Medicare coverage by removing the hearing aid exclusion from the law. There’s no reason to delay action on this any longer. Are our representatives listening?

Mary C. White is an adjunct professor of environmental health at Emory University’s Rollins School of Public Health, a Public Voices fellow at AcademyHealth in partnership with the OpEd Project and a former federal epidemiologist.

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Second human case of bird flu detected in Michigan dairy worker

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Second human case of bird flu detected in Michigan dairy worker

A second human case of bird flu in a diary worker has been confirmed in Michigan, state and federal health officials announced Wednesday.

The symptoms were mild, consisting of conjunctivitis. The Texas dairy worker who contracted the virus in March also came down with pink eye.

At a press call on Wednesday, Nirav Shah, principal deputy director of the U.S. Centers for Disease Control and Prevention, said the finding was “not unexpected” and that it was a scenario “that we had been preparing for.”

He said that since the discovery of H5N1 in dairy cattle, state and federal health officials have been closely monitoring farmworkers and slaughterhouse workers and urging farmers and farmworker organizations to “be alert, not alarmed.”

Federal officials say they still believe the human health risk of bird flu is low; however, it underscores the need for people who are interacting with infected or potentially infected farm animals or birds to take precautions, including avoiding dead animals and wearing personal protective equipment (PPE) if there’s a need to be in close contact.

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Though a nasal swab from the person in Michigan tested negative for influenza, an eye swab from the patient was shipped to the CDC and tested positive for influenza A(H5N1) virus.

This is the third case of H5N1 reported in the United States. A poultry worker in Colorado was identified in 2022.

Although the symptoms in the three farmworkers in the U.S. have been mild, people elsewhere in the world have suffered more severe illness, including death. According to the World Health Organization, between Jan. 1, 2003, and March 28, 2024, there have been 888 cases of human infection from 23 countries; 463 were fatal.

In preparation for a more widespread outbreak, the CDC updated its guidance for PPE in dairies and issued a nationwide order for healthcare providers to be on the lookout for novel influenza.

On Tuesday, the CDC asked clinical laboratories and health departments to increase the number of influenza samples being analyzed “to maximize the likelihood of catching a case of H5N1 in the community,” Shah said.

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The US Department of Agriculture is also expanding its surveillance and support by providing $1500 to non-infected farms to beef up biosecurity, and $100 to producers who want to buy inline samplers to test their milk. The agency will also provide $2000 per farm to cover veterinary fees for testing, as well as shipping costs to send those tests to laboratories for analysis.

There have been no cases of H5N1 detected in California’s dairy herds.

Officials said ongoing analysis of the nation’s dairy supply suggests it is safe to consume, Despite the risk to human health being low, an official with the Administration for Strategic Preparedness and Response said it will make Tamiflu available upon request “to jurisdictions that do not have their own stockpile and are responding to pre-symptomatic persons with exposure to confirmed or suspected infected birds, cattle or other animal exposures.”

Dawn O’Connell, assistant secretary of the preparedness agency, said it started the “fill and finish” process for approximately 4.8 million doses of vaccine “that is well matched to the currently circulating strain of H5N1 through the national pre-pandemic influenza vaccine stockpile program.”

She said the decision to get started on H5N1 vaccines was not a response to any heightened concern, but since it takes several months to fill and finish vaccine doses, the agency “thought it made sense given what we were seeing.”

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Gas stoves may contribute to early deaths and childhood asthma, new Stanford study finds

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Gas stoves may contribute to early deaths and childhood asthma, new Stanford study finds

Lung-irritating pollution created by cooking with gas stoves may be contributing to tens of thousands of premature deaths and cases of childhood asthma in the United States, according to a new study published in the journal Science Advances.

For decades, scientists have known the flames from a gas stovetop produce nitrogen dioxide, a pungent gas that can inflame a person’s lungs when inhaled. But for the first time, a team of researchers from Stanford University and Oakland-based research institute PSE Healthy Energy published a nationwide estimate of the long-term health consequences associated with cooking with natural gas and propane stoves.

Researchers concluded that exposure to nitrogen dioxide emissions alone may contribute to nearly 19,000 premature deaths in the United States each year. It has also resulted in as many as 200,000 current cases of pediatric asthma compared with cooking with electric stoves, which do not produce nitrogen dioxide.

Aggressive and impactful reporting on climate change, the environment, health and science.

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Stanford researcher Yannai Kashtan noted higher levels of pollution were correlated with the amount of gas that was burned. But pollution also accumulated at higher levels inside smaller homes.

“If you live in a smaller house, you’re exposed to more pollution, and that can lead to income and racial disparities in exposure,” Kashtan said. “In general, folks living in neighborhoods with higher levels of outdoor pollution also tend to have higher indoor pollution. So this environmental injustice extends indoors as well.”

The American Gas Assn., a trade organization representing more than 200 local energy companies nationwide, dismissed the findings as “misleading and unsupported.”

“Despite the impressive names on this study, the data presented here clearly does not support any linkages between gas stoves and childhood asthma or adult mortality,” the association’s president and CEO, Karen Harbert said in a statement earlier this month.

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The study is the latest examining the serious health effects associated with breathing fumes from gas stoves, which release planet-warming carbon emissions and a variety of air pollutants. In recent years, the popular household appliance has become a political hot-button issue as policymakers and regulators have weighed environmental impacts against consumer choice.

Many large cities in California, including Los Angeles, have moved toward phasing out gas stoves in newly constructed residences. Earlier this month, the California Assembly advanced a bill to the Senate that would require gas stoves to come with warning labels detailing the pollution and health effects that can arise from cooking with gas.

Gas stoves emit a variety of pollutants, including asphyxiating carbon monoxide, cancer-causing formaldehyde and benzene. The flame also creates nitrogen dioxide, a precursor to smog and a pollutant that can cause difficulty breathing.

Environmental groups say consumers should be notified about these pollutants and the potential harm they can cause.

“Gas stoves create pollution in our homes, increasing the risk of childhood asthma and other respiratory problems for our families,” said Jenn Engstrom, state director for California Public Interest Research Group. “However, this risk has largely been hidden from the public. Consumers deserve the truth when it comes to the danger of cooking with gas. Warning labels will give consumers what they need to make informed decisions when they purchase appliances for their homes.”

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Kashtan and other researchers had previously discovered cooking with gas stoves presented a similar cancer risk as inhaling second-hand cigarette smoke. They also found some gas stoves leaked contaminants even when the burners were off.

The effects are especially devastating to children, whose smaller and still-developing lungs need to take more breaths than adults, Kashtan said. Older adults, especially those with cardiovascular or respiratory illness, are also more vulnerable to pollution from gas stoves.

To alleviate indoor air pollution, experts recommend using ventilation hoods and opening windows while cooking,

Starting in 2008, California required new and redeveloped homes to have ventilation that could prevent pollution from building up indoors. But during their research, measuring emissions in more than 100 households across the country, Yannai said they found many kitchens didn’t have ventilation hoods at all.

Although the health effects of breathing these pollutants are clear, researchers still wonder to what degree these conditions could be reversible. As communities take steps to mitigate their exposure or transition away, he said we could soon see the results.

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“It’s never too late to stop breathing in pollution,” he said.

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