Proposed rule would end requirement for faith-based health-care providers to refer for services they won't perform

"The Department of Health and Human Services has unveiled a proposed rule that would remove a mandate that faith-based providers refer patients to other providers for services they won't offer for religious reasons," John Commins reports for HealthLeaders, a health-care industry publication.

If adopted, the rule could hurt rural patients. At Catholic hospitals, which make up an increasing share of rural health systems, providers often can't offer services related to abortion, birth control, some end-of-life care, and gender affirmation. Rural patients who are refused care because of religious beliefs may have no other local options, as illustrated by a recent story about a Minnesota woman who had to drive for hours and contact several pharmacies to get a morning-after pill. 

The proposal "removes what the Trump administration claims is a discriminatory Obama-era policy that requires religious providers of social services, but not other providers of social services, to make referrals," Commins reports. "HHS is one of nine federal departments, including the Department of Education and the Department of Justice, that were named in a Trump executive order to remove what it said were unfair barriers in federal policies that singled out faith-based groups."

Rural Minn. woman sues after two pharmacists refuse to fill morning-after pill prescription because of religious beliefs

McGregor in Aitkin County (Wikipedia)

A rural Minnesota woman has filed suit after two pharmacists refused to sell her emergency contraception because of their religious beliefs. She says the issue highlights how religious-objection rules hurt rural women, Katie Shepherd reports for The Washington Post.

Andrew Anderson, 39, lives in McGregor, a town of about 400 people. She and her longtime partner have one biological child and four adopted or foster children. When their condom broke in January 2019, Anderson called her gynecologist the next morning and received a prescription for Ella, an emergency contraceptive. The prescription was sent to Thrifty White Pharmacy, the only one in McGregor.

The pharmacist at Thrifty White, George Badeaux, refused to fill Anderson's prescription because he said it would be against his religious beliefs. Badeaux, who is also a pastor at a nearby church, advised her not to go to a nearby pharmacy because the employees there would also probably refuse to fill the prescription, Shepherd reports.

"Anderson did not give up. She drove about 20 miles to a CVS pharmacy in a neighboring town, where another pharmacist declined to fill her prescription," Shepherd writes. "Anderson said that pharmacist, who is not named in the suit, told her the pharmacy did not have Ella in stock and could not get it from a wholesale provider in time for her to take the pill, which must be taken within five days of unprotected sex.

Anderson said the CVS pharmacist called a Walgreens in Brainerd, more than 50 miles from her home, and told her that it didn't have the pill. However, when Anderson called the Walgreens herself, the pharmacist there confirmed that the CVS pharmacist had just called, and said the store did have Ella in stock and would be happy to fill her prescription the next day, Shepherd reports. She and her young son made a three-hour round trip in a blizzard to fill the prescription, he writes.

Anderson sued Badeaux, Thrifty White, and the unnamed CVS pharmacist who refused to fill her prescription and misinformed her about its availability at the Brainerd Walgreens. She notes in her lawsuit that, though Minnesota allows pharmacists to refuse to fill emergency contraception prescriptions because of personal beliefs, the law requires the objecting pharmacist to help the patient find another way to fill the prescription, and neither pharmacist did that, Shepherd reports.

"The lawsuit argues that refusing to provide women access to the morning-after pill is a form of sex discrimination and violates people’s civil rights," Shepherd reports. "Anderson said she believes rural women are particularly at risk to have their medical needs overshadowed by a pharmacist’s personal beliefs because there are so few places to buy medication."

Mobile clinic brings better contraception to South Texas

The UT Health Rio Grande Valley mobile health clinic (Undark photo by Charlotte Huff)

A mobile clinic is bringing more effective contraception to rural areas in South Texas, Charlotte Huff reports for Undark, a nonprofit news organization that writes about scientific issues that intersect with policy and society.

The clinic is the brainchild of two professors and a hospital executive. It started with Joseph Potter, a sociology professor at the University of Texas at Austin who studied postpartum access to contraception in 2016, Huff reports. Of the 1,700 new mothers studied at eight Texas hospitals, almost all were Medicaid patients, and over three-fourths were interested in sterilization or a long-acting reversible contraception (LARC) such as an intrauterine device or implant after childbirth. But six months later almost half were using cheaper, less reliable methods like condoms or withdrawal.

Though LARCs are the most effective form of birth control on the market, only about 11 percent of U.S. women use them. Texas Medicaid does not cover them unless they're inserted immediately after childbirth, and new mothers must pay a separate fee for the insertion. Since the devices alone cost about $750, most low-income women can't afford them unless they get one right after childbirth, and the high cost keeps many hospitals and clinics from stocking them even if the mothers did want them, Huff reports. Texas did not begin covering postpartum intrauterine devices until 2016.

Tony Ogburn, obstetrics and gynecology chair at the University of Texas Rio Grande Valley's medical school, wanted to improve women's health in the area, especially after reading Potter's research. They teamed with Aida Gonzales, vice president of DHR Health Women's Hospital in Edinburg, near the southern tip of the state, and came up with the idea of the mobile clinic. "By cobbling together several grants, and teaming up with Women’s Hospital, they’ve so far been able to provide the devices at little to no cost through the medical school’s outpatient obstetrics/gynecology clinic, a mobile outreach effort, and at the hospital immediately after delivery," Huff reports.

The trio have tried to expand area access to intrauterine devices in ways besides the mobile clinic. Ogburn has ensured that his medical students learn how to insert the devices and how to counsel women interested in a LARC while being sensitive to their opinions about childbearing and religion (most of the women are Catholic, a denomination that discourages some birth control methods). Women's Hospital has also been stocking IUDs; over two-thirds have been paid for by an anonymous donor, and the hospital has been able to get insurance or Medicaid to pay for the rest, Huff reports.

Anti-abortion rule prompts rejections of family-planning funds; CVS squeezes mail-order contraceptive sellers

Rural residents may soon find it more difficult to access some forms of reproductive health care.

Planned Parenthood and some other reproductive-health providers, including some governments, have announced they will stop taking about $60 million in annual federal funding for low-income women's reproductive health services because a new Trump administration rule bars grantees from making referrals for abortions. "That loss in federal funding could deliver a heavy blow to already cash-strapped, non-profit clinics that are often the only providers in their communities offering low cost services," particularly in rural areas, Jessie Hellman reports for The Hill. "Other organizations, including Maine Family Planning, have dropped out of the program because of the new rule. Governors in Hawaii, Illinois, New York, Oregon and Washington have all stated they will withdraw . . . and state legislatures in Maryland and Massachusetts have passed laws saying they would."

The family-planning program, Title X, has provided birth control and other reproductive care to young, poor women for almost 50 years. It serves about 4 million patients a year, most of them black or Hispanic, and sends $260 million a year to clinics. "The program has helped fill gaps in health care access including cancer screenings, STD testing and annual exams for women who are poor or don't have health insurance. It does not fund abortion care," Nicquel Ellis reports for USA Today. "Planned Parenthood has been the largest provider, serving 40 percent of all Title X patients."

Program participants had to submit statements to the government by Monday saying they would comply with the new rule, which will be enforced starting Sept. 18. "In addition to the ban on abortion referrals by clinics, the new Title X rules include financial separation from facilities that provide abortions, designating abortion counseling as optional instead of standard practice and limiting which staff members can discuss abortion with patients," Ellis reports. "Clinics would have until next March to separate their office space and examination rooms from the physical facilities of providers that offer abortions."

Planned Parenthood is the only Title X recipient in some areas—such as the entire state of Utah—and serves a disproportionate amount of the poor in other places, including many rural areas. Alexis McGill Johnson, the acting president and CEO of the Planned Parenthood Federation of America, said that if Planned Parenthood facilities are forced to scale back or close, it will be impossible for other health centers to fill the gap, Ellis reports.

"Planned Parenthood and a host of states are suing the administration, with an appeals court holding hearings next month," Hellman reports.

Meanwhile, in July CVS Caremark began reimbursing mail-order prescription delivery companies less, including birth-control service Pill Club. Pill Club protests that the rate change threatens its ability to keep operating, Garnet Henderson reports for Vice.

Mail-order services like Pill Club, Nurx, and Pandia Health allow patients to get a prescription via virtual consultation with a doctor, then deliver the meds by mail. It's popular in rural areas, especially for women who don't have insurance or have other difficulties finding reproductive care. "According to Pill Club, 70 percent of its users previously had difficulties obtaining birth control, and 55 percent said they would have to stop taking birth control without Pill Club," Henderson reports.

CVS Caremark is a pharmacy-benefits manager, a third-party company that manages prescription benefits on behalf of insurers and Medicaid programs. It's a subsidiary of CVS Health and sister to the ubiquitous CVS Pharmacy chain. A CVS Caremark spokesperson confirmed the rate change, but said Pill Club's accusations were "extremely misleading" and that the decision was not specifically aimed at, nor would have any impact on, access to contraceptives, Henderson reports.

Sophia Yen, CEO and co-founder of Pandia Health, said small pharmacies (which is essentially what such services are) are threatened because they can't get discounts by buying in huge volumes like the top three or four pharmacy benefit managers can. She also noted that CVS offers its own mail-order service, and suggested the move might be an attempt to undercut competition, Henderson reports.

Feds postpone anti-abortion 'conscience rule' for medical providers that could disproportionately affect rural areas

The Trump administration has agreed to postpone a rule that would allow medical workers to decline to participate in abortions "or other treatments on moral or religious grounds while the so-called 'conscience' rule is challenged in a California court," The Associated Press reports. "The rule was supposed to take effect on July 22, but the U.S. Department of Health and Human Services and its opponents in a California lawsuit mutually agreed Friday to delay a final ruling on the matter until Nov. 22."

Though such a rule is likely more popular in rural areas, which tend to be more socially conservative, it could also disproportionately affect rural residents since there are fewer pharmacies and medical providers. Women who want to fill a prescription for birth control pills or abortifacients, or be provided emergency contraception after a rape from a hospital, may not have the means to travel to get those things if they are denied at facilities closer to home.

The Trump administration's proposed rule "would require institutions that receive money from federal programs to certify that they comply with some 25 federal laws protecting conscience and religious rights," the AP reports. The California lawsuit  "alleges that the department exceeded its authority with the rule, which President Trump announced in May."

Sexually transmitted diseases are on the rise as funding to prevent and treat them falls

Health officials are worried about this strain of gonorrhea that
is resistant to antibiotics. (Centers for Disease Control photo)

"Health officials are tracking record-breaking rates of sexually transmitted disease, including a resurgence of some infections which had been considered rare, such as gonorrhea and syphilis. These STDs are on the rise amid cuts to public health budgets dedicated to testing, prevention, and public outreach," Mary Meehan reports for Ohio Valley ReSource, which covers Kentucky, Ohio and West Virginia.

The Centers for Disease Control and Prevention reported 2.4 million new cases of STDs in 2017; about 40 percent of those were among people aged 15 to 25. The number of babies born with syphilis increased from 362 in 2013 to 918 in 2017, mostly in Southern and Western states. In some Ohio Valley communities, chlamydia infections rose more than 200 percent and gonorrhea rose 1,000 percent or more between 2011 and 2017, Meehan reports.

The surge among younger people could stem from a greater likelihood to engage in risky sexual behavior. Jim Thacker, spokesperson for the Madison County Health Department in Kentucky, told Meehan that people born after the AIDS epidemic was largely contained may be less fearful about STDs. And the availability of effective, long-term birth control might make young adults and teens less prone to use condoms, he said.

Some of those affected by STDs are much younger than teens: according to a recent CDC report, more infants are dying after catching syphilis from their mothers during birth. Syphilis is easily treated with antibiotics, but an untreated pregnant woman has up to an 80 percent chance of passing it on to her baby during birth, Meehan reports.

Matt Prior, spokesperson for the nonprofit National Coalition of STD Directors, told Meehan that STDs are a public health crisis often hitting areas already hurting from the opioid epidemic, such as Appalachia.  Meehan reports, "As rates go up, Prior said, funding has gone down. So while STDs have increased by 30 percent in the last five years to reach an all-time high, the amount of federal money for prevention and education has consistently gone down since 2003. Prior says that federal funding is critical for states like Kentucky, West Virginia and Ohio."

Prior told Meehan, "The federal STD prevention line is the only line or funding streams these states have so it is really the first and last line of defense."

Catholic hospitals play bigger role in rural health care

Some hospitals on the 2011 map don't appear on the 2016 map either because they're no longer associated with a
Catholic institution or because they're no longer classified as the sole community hospital. (FiveThirtyEight map)

More and more, rural residents' access to some health care services may be determined by the doctrine of the Roman Catholic Church.

"In a growing number of communities around the country, especially in rural areas, patients and physicians have access to just one hospital. And in more and more places, that hospital is Catholic," Anna Maria Barry-Jester and Amelia Thomson-DeVeaux report for FiveThirtyEight. "That sounds innocuous — a hospital is a hospital, after all. But Catholic hospitals are bound by a range of restrictions on care that are determined by religious authorities, with very little input from medical staff. Increasingly, where a patient lives can determine whether Catholic doctrine, and how the local bishop interprets that doctrine, will decide what kind of care she can get."

Commonly affected services include abortion, birth control, some end-of-life care, and gender-affirmation procedures. Some doctors who had worked at Catholic hospitals told the reporters that they had been unable to give what they felt was the most effective treatment to some patients because of religious restrictions. Some low-income women are not able to go elsewhere for services not provided by Catholic hospitals, due to financial and transportation challenges.

Catholic hospitals have had some latitude to deny certain treatment options for decades, but that power has been expanded under recent moves by the Trump administration. President Trump signed an executive order saying his administration would protect religious freedom, then the Department of Health and Human Services ruled that large employers don't have to cover birth control for employees. HHS also created a Conscience and Religious Freedom Division to focus on protecting employers' rights.

Nationwide, "best estimates suggest that one in six hospital beds and many of the nation’s largest nonprofit health systems are Catholic-owned or -affiliated," Barry-Jester and Thomson-DeVeaux report. "From 2001 to 2016, the number of Catholic-affiliated hospitals in the U.S. grew by 22 percent, even as the total number of hospitals in the U.S. shrunk, according to research by MergerWatch and the American Civil Liberties Union. And the changes vary by region. In Washington state, more than 40 percent of hospital beds are in Catholic institutions. In several Midwestern states, more than 30 percent of beds are in Catholic hospitals.

This is partly because Catholic hospitals may be able to weather financial hardship better because of their nonprofit status, efficiency, and access to Catholic church funding.

In a region and state with many teen births, E. Ky. program helps young women teach sex ed outside the classroom

All Access EKY trains young Eastern Kentucky women to make
media campaigns for birth control. (Photo by Hero Images/Getty Images)

A group called All Access EKY is hiring young Eastern Kentucky women between 17 and 22 to create media campaigns for reproductive health, with a focus on increasing access to a full spectrum of birth-control options in Eastern Kentucky, Ivy Brashear reports for Yes! Magazine.

Barriers to getting birth control in Eastern Kentucky are "profound," Brashear reports, and extend way beyond the ordinary obstacles of cost and access to care, to things like having access to reliable transportation (there is no public transportation), knowing if the employees at the clinic go to the same church as your parents, or simply finding a doctor who is willing to prescribe it.

"This is all assuming she knows anything about her birth-control options in the first place," Brashear writes, adding that many young women in Eastern Kentucky "must battle abstinence-only sex education in their schools and a cultural veil of secrecy about their bodies in order to fully understand their options."

She reports that only six of the 19 health departments and federally qualified health clinics in All Access EKY's seven counties offer the full range of birth-control options, and have only four nurse practitioners at public health clinics who are qualified to insert intrauterine devices (IUDs). And the region has a high rate of teen births, Kentucky Health News reports.

All Access, which began in 2016, is working to overcome these barriers by offering young women from the region an eight-week paid fellowship to create educational films that focus on birth control, with interviews of local women about their reproductive health experiences.

The women have also produced social-media campaigns, set up tables at local festivals, and distributed printed materials through clinics and local businesses, Brashear reports in her story, titled "Where Birth Control is Scarce, Young Women Create Sex Education Outside the Classroom."

All Access is a collaboration between the Kentucky Health Justice Network, the national nonprofit Power to Decide, and Appalshop, the media and arts organization in Whitesburg, where the project is housed.

Rural women start having sex earlier, are likelier to have more kids, and use more reliable methods of birth control

Centers for Disease Control and Prevention chart

A new analysis of federal data by the National Survey of Family Growth found that women in the rural U.S. tend to have sex earlier, and have more children than their urban counterparts. They are also more likely to report choosing long-term or permanent methods of birth control because more reversible methods like condoms are less likely to be accessible. The researchers analyzed responses from in-person interviews with more than 10,000 women ages 18-44, between 2011 and 2015.

"On average, women living in rural areas said they had their first sexual encounter earlier than women living in urban areas, according to the survey. The mean age of first sexual intercourse among women living in rural areas was 16.6 years old. For women living in urban areas, the average age of first intercourse was 17.4," Patti Neighmond reports for NPR.

About 41 percent of metro-area women had no children, significantly more than the 30 percent in rural areas. And women in rural areas are slightly more likely to have two or more children than women in urban areas are.

"When asked about contraception, one in five women in both groups reported they'd had sexual intercourse without using contraception. And, notably, more women in urban areas reported using less effective birth control methods to prevent pregnancy (a condom or withdrawal, for example) than their rural counterparts, who were more likely to use one of the most effective contraceptive methods — an IUD or sterilization," Neighmond reports.

Eleanor Bimla Schwarz, a research epidemiologist at the University of California, Davis, who wasn't involved in the study, told Neighmond that the difference in birth-control methods likely stems from the fact that women in rural areas can't access reversible methods of birth control as easily. "If we really want to help young women and teens have a healthy and safe sexual life, we need to get effective resources and education to them before 16," she said.