As the University of California’s health system renews contracts with hundreds of outside hospitals and clinics — many with religious affiliations — some of its doctors and faculty want stronger language to ensure that physicians can perform the treatments they deem appropriate, including abortions for women or hysterectomies for transgender patients.

University of California Health is in the middle of a two-year process to renew contracts with affiliate hospitals and clinics that help the university deliver care in underserved parts of the state. Many of the agreements are with faith-based facilities, including prominent hospitals operated by Dignity Health, Providence, or Adventist Health. Such arrangements generate more than $20 million a year for the UC system and help the public university approach its goal of improving public health.

The current policy, adopted in 2021, states that UC physicians have the freedom to advise, refer, prescribe, or provide emergency care, covering cases in which moving a patient “would risk material deterioration to the patient’s condition.” But some UC doctors and faculty worry that physicians would be allowed to perform certain surgeries only in an emergency.

They want to add a clause stating that physicians have the right to perform procedures in a manner they deem advisable or necessary without waiting for the patient’s condition to get worse.

Others have gone so far as to urge the university to reject partnerships with hospitals that have ethical and religious directives against sterilization, abortion, some miscarriage management procedures, and some gender-affirming treatments. The Academic Senate, a faculty body that helps the university set academic policies, and other faculty councils urged the university’s president to avoid working with health care facilities because many have restrictions that “have the potential for discriminatory impact on patients.”

In response, university leaders have pledged publicly to ensure that doctors and trainees can provide whatever care they deem necessary at affiliated facilities but haven’t made changes to the policy language.

“We’ve made it clear that the treating provider is the one to decide if an emergency exists and when to act,” said Dr. Carrie Byington, executive vice president for University of California Health, at a fall meeting of the UC Board of Regents, the governing board of the university system.

UC Health has given itself until the end of this year to make contracts conform to its new policy. During the October board meeting, staffers estimated that one-third of the contracts had been evaluated. Administrators haven’t said whether the current policy thwarted any contracts.

Back in June 2021, the regents approved the policy governing how its doctors practice at outside hospitals and clinics with religious or ethical restrictions. Regent John Pérez made significant amendments to a staff proposal. At the time, it was celebrated as a win by those advocating for the university to push back on religious directives from affiliates.

Pérez noted at the time that his amendments were aimed at “making clear that it’s the regents’ expectation in policy that nothing that is not based on science or [the] best practice of medicine should limit the ability of our practitioners to practice medicine in the interest of the patients.”

But some doctors and faculty said Pérez’s proposal was then wordsmithed as it was converted from the regents’ vote into a formal policy months later. Some questioned whether the policy could be interpreted as restricting services unless there is an emergency, and said it does not go far enough to define an emergency.

“It sounds pretty good,” Dr. Tabetha Harken, director of the Complex Family Planning, Obstetrics & Gynecology division at the UC Irvine School of Medicine, testified before the board. “It passes the commonsense test, but in reality, this is just the federal minimum requirement of care.”

Pérez declined to comment to KHN.

At the regents’ meetings, concerned doctors offered examples of pregnancy and gender-affirming care they believe would be at risk in some hospitals.

One was tubal ligation or sterilization procedures immediately after birth to prevent future pregnancies that may put the woman at risk. It’s a simpler procedure if done postpartum because the uterus is larger than normal and it eliminates the need for additional surgery, said Dr. Jennifer Kerns, an associate professor at UC-San Francisco and director of the school’s Complex Family Planning Fellowship.

Dr. Mya Zapata of UCLA Health described cases of two patients who might not be able to get the same care at a religiously restricted hospital: a trans male who seeks out a hysterectomy based on a mental health referral for gender-affirming surgery, and a cisgender female who seeks out the same procedure for uterine fibroids.

In a hospital with restrictions, Zapata said, the cisgender patient would be able to get the surgery but the trans patient would not, despite both being considered nonemergency cases.

But it’s unclear if physicians are running into problems. UC Health leaders said there have been no formal complaints from university doctors or trainees practicing at affiliate medical centers about being blocked from providing care.

Critics said the lack of complaints may not reflect reality since physicians may find workarounds by transferring or referring patients elsewhere. One researcher, Lori Freedman, who works at UCSF, has spoken to dozens of doctors working at religious-affiliated hospitals across the country. Many have not filed complaints about care restrictions out of fear they’d put their job at risk, she said.

The debate stems from a partnership with Dignity Health, a Catholic-affiliated hospital system. In 2019, UCSF Medical Center leaders considered a controversial plan to create a formal affiliation with Dignity. Critics voiced opposition in heated public meetings, and the plan drew condemnation from dozens of reproductive justice advocates and the gay and transgender communities. UCSF ultimately backed off the plan.

When it became clear that UC medical centers across the state had similar affiliation contracts, faculty members raised additional concerns. Janet Napolitano, then president of the UC system, convened a working group to evaluate the consequences of ending all agreements with organizations that have religious restrictions. Ultimately, the group stressed the importance of maintaining partnerships to provide care to medically underserved populations.

“With 1 in 7 patients in the U.S. being cared for in a Catholic hospital,” the group wrote in its report, “UC’s isolating itself from major participants in the health care system would undermine our mission.”

Dignity Health, which merged in 2019 with Catholic Health Initiatives to form CommonSpirit Health, has already reached a new contract that adopts the updated UC policy. Chad Burns, a spokesperson for Dignity, said the hospital system values working with UC Health for its expertise in specialties, such as pediatric trauma, cancer, HIV, and mental health. He added that the updated agreement reflects “the shared values of UC and Dignity Health.”

Some UC doctors point out that they have not only public support, but legal standing to perform a variety of reproductive and contraceptive treatments. After California voters passed Proposition 1, the state constitution was officially changed in December to affirm that people have a right to choose to have an abortion or use contraceptives. Unlike health systems in other states, some faculty say UC Health can assert reproductive rights.

“We have a lot of latitude, being in California, to be able to make these decisions and stand in our power,” Kerns said. “I think it’s our responsibility to do so.”

“Partnering with faith-based institutions dedicated to serving vulnerable populations affords opportunities to patients who are least able to navigate our complex health systems,” she said.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

The Florida Board of Medicine voted Nov. 4 to approve a rule that barred physicians from performing surgical procedures on minors to alter “primary or secondary sexual characteristics” and from prescribing them medication to suppress puberty and hormones. The rule included an exception for patients who were already receiving those treatments.

Two days later, Florida’s Republican governor, Ron DeSantis, said gender-affirming care is “an example of ideology overtaking the practice of medicine,” touting that he worked with the board to take a stand against it.

“Over 80% of the dysphoria amongst teenagers resolves itself by the time they become older,” DeSantis said during a Nov. 6 campaign event. “So why are you mutilating their body parts?”

Earlier in the year, the Florida Department of Health used the statistic as it advised against medical transitioning for minors. The department’s April memo said that “80% of those seeking clinical care will lose their desire to identify with the non-birth sex.”

Dr. Hector Vila, a Tampa anesthesiologist and member of the governor-appointed board, said he supported the rule because a “significant percentage” of transgender children will return to their assigned sex.

PolitiFact consulted with experts and data to determine whether gender incongruence will “resolve itself” for a large cohort of teenagers.

Those experts said Florida mischaracterized a statistic linked to an academic review from 2016. What’s more, one of the researchers whose work is cited as the statistic’s source has said the data he consulted is not “optimal” and can lead to “wrong inferences.”

The public comment period for the rule ended Dec. 5.

The 80% figure comes from a 2016 paper published in the International Review of Psychiatry.

Dutch health psychologist Thomas Steensma and Italian psychologist Jiska Ristori examined past studies on gender dysphoria, which describes the distress people may experience because of a discrepancy between their gender identity and the sex assigned to them at birth.

Not all transgender people experience or are diagnosed with gender dysphoria. Gender dysphoria diagnoses focus on gender identity-related psychological distress, not gender identity itself.

The researchers wanted to know whether people who experienced gender dysphoria as children still had it later in life. They looked at the outcomes for children involved with 10 studies conducted from 1968 to 2012 in the U.S., Canada, and the Netherlands.

Their review of the studies said they showed that gender dysphoric feelings went away for 85% of children “around or after puberty” — while acknowledging several limitations.

“There may be a number of arguments to nuance this high percentage of desistence,” the review read. “The lower persistence rates in the earlier studies, compared to the more recent studies after 2000, may be the result of the inclusion of less extreme cases in the earlier studies than in later studies.”

In other contexts, “desistence” can refer to an apparent end of gender variance and a return to an identity that aligns with the sex assigned at birth. In the paper, the researchers meant the lifting of dysphoric feelings.

Other experts mentioned concerns with the methodology of studies cited in the paper.

Dr. Kristin Dayton, a pediatric endocrinologist, said the studies had a small share of children assigned female at birth — and are thus not representative samples of the population. Eight of the 10 studies examined only children assigned male at birth.

At least six of the studies were conducted before the American Psychiatric Association developed a formal diagnosis for gender dysphoria in children. Some of the 10 studies did not include children who were referred to the studies by medical professionals.

A 1987 study, for instance, used advertisements to recruit children. Only 30% of the children examined had “frequently” stated a desire to be a girl. Experts said most of the children in that study wouldn’t have met the current criteria for gender dysphoria.

The diagnostic criteria for the condition include a “marked incongruence” between one’s experienced gender and assigned sex at birth lasting at least six months and a “strong desire to be of the other gender or an insistence that one is the other gender.”

Florida’s Department of Health and Board of Medicine misrepresented the review’s conclusion by stating 80% of children will “lose the desire” to identify with a sex not assigned at birth.

The 80% figure in the review did not reference children’s gender identities; it centered on the persistence and desistence of gender dysphoria in adulthood. Steensma later wrote that “using the term desistence in this way does not imply anything about the identity of the desisters.”

Although the review noted the studies found that gender dysphoria in childhood is “strongly associated” with a “lesbian, gay, or bisexual outcome,” it did not say what percentage of people studied stopped identifying as transgender.

“The 80% statistic, used by the Florida Department of Health and the state’s leadership, is categorically false,” Dr. Meredithe McNamara, an assistant professor of pediatrics at the Yale School of Medicine, told PolitiFact. “After a close read of the scholarship cited by the state, the state’s conclusion simply cannot be drawn in good faith.”

Steensma, who did not respond to PolitiFact’s requests for an interview, has responded to criticism from colleagues about how his research is used to discourage social and medical affirmation for gender diverse adolescents.

McNamara also said that Florida’s reliance on a 2016 paper is a “glaring problem” because the state neglected to consider about six years of new research.

A study published in July, for instance, sought to develop an estimate of transgender children who later stop identifying with a gender that is incongruent with their assigned sex. It evaluated 300 transgender children over five years. To participate in the study, children must have already begun social transitioning, which often involves changing names, haircuts, and pronouns.

Researchers from Princeton University’s TransYouth Project followed up with participants in person and online. At the end of the five years, 94% of participants still identified as transgender.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

This spring, a Chevron worker testified that the company revoked health coverage for hundreds of members of the United Steelworkers Local 5 at the Richmond refinery during a strike that ultimately lasted two months.

Thousands of nurses at Stanford Health Care were told in April they would lose their health insurance if they did not return to work during their weeklong strike.

More than 300 workers at Sequoia Hospital in Redwood City received a similar message after going on strike in mid-July as contract negotiations stalled.

Freezing health insurance benefits is a common tactic in a labor dispute because, without them, workers might be more easily persuaded to concede to management’s demands. But California lawmakers are giving an edge to strikers.

Assemblymember Jim Wood, a Democrat, is hoping a new California law he authored will dissuade employers from cutting off health benefits during labor disputes by allowing private-industry workers to maximize state subsidies for coverage purchased through Covered California, the state’s health insurance marketplace. The bill, which takes effect in July, was sponsored by the California Labor Federation, California Teamsters Public Affairs Council and the Los Angeles County Federation of Labor.

“The goal of the legislation is to say, ‘No you can’t do this,’” Wood said. “Never try it again.”

According to Covered California spokesperson Kelly Green, eligible workers will have their premiums covered as if their incomes were just above the Medicaid eligibility level.

The state would factor in the worker’s federal subsidy and cover the difference. For example, a single person making $54,360 a year may pay 8.5% of their income, or about $385 a month, on premiums under a middle-tier health plan. Under the new law for striking workers, that person selecting the same plan would pay nothing in premiums — as if that person made $20,385 a year — for the duration of the strike.

The federal government authorized an enhanced subsidy under the American Rescue Plan Act. The enhanced subsidy will continue through 2025 under the Inflation Reduction Act. The state’s share of the subsidy could increase once the federal boost ends.

One estimate that unions shared with the state suggested the law would cost California an average of $341 a month per worker — with strikes lasting one to two months. Labor groups estimate the bill will affect fewer than 5,000 workers a year. California has nearly 15 million workers in the private sector, and strikes are generally a tool of last resort in labor negotiations.

It’s not clear how businesses will respond. Chevron, Stanford Health Care and Sequoia Hospital’s operator, Dignity Health, did not respond to requests for comment. The bill met no formal opposition from businesses or taxpayer groups. Covered California’s subsidies are footed by a mix of federal and state funds as part of the Affordable Care Act, so there’s no direct cost to businesses.

Last year, Gov. Gavin Newsom, a Democrat, signed the Public Employee Health Protection Act, which bars public employers from terminating health coverage during an authorized strike. The new law for the private industry is different: There’s no ban on — or financial penalty for — revoking health benefits during strikes.

Nationally, Democrats in the House and Senate have pushed for an outright ban on this practice, but neither bill has advanced out of committee.

When California workers lose their employer-sponsored health benefits, they may become eligible for the state’s Medicaid program, known as Medi-Cal, or qualify to purchase health insurance through Covered California. With the latter option, workers could receive a range of subsidies to help pay for their monthly premiums. Generally, the lower a household’s income, the bigger the subsidy.

But even when workers do qualify for Covered California, that insurance can be much more expensive than the plans they had through their job — sometimes consuming 30% to 40% of their income, proponents said. And striking workers may experience delays since coverage may not take effect until the following month.

“This is one of the drawbacks of having a health care system that is tied to employment,” said Laurel Lucia, health care program director at the University of California-Berkeley Labor Center. “We saw during the pandemic, when there were furloughs or layoffs, people lost job-based coverage when they needed it most.”

Striking Sequoia workers reached an agreement with Dignity Health and returned to the 208-bed facility before health coverage stopped on Aug. 1, but some said they might have stayed on the picket line longer if not for fear of losing their benefits.

“That was pretty scary,” said Mele Rosiles, a certified nursing assistant and a member of the union’s bargaining team who was pregnant at the time. “A majority of our workers felt threatened by this move from our employer to strip our family’s health insurance if we didn’t return to work.”

Covered California estimates it will spend about $1.4 million to launch this benefit. The agency said it will create application questions to screen for eligible workers and remind them to stop coverage once they go back to work.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Watch enough TikTok videos and you’re sure to see one extolling a special kind of do-it-yourself dentistry. Not about brushing and flossing, except maybe flossing with strands of your hair. These are videos on drilling into your teeth and cementing gems to them or filing your teeth to reshape them.

People have been styling their teeth for centuries across the globe throughout North and South America, Africa, and Asia. But social media — particularly TikTok, where everything old and new is nip/tucked into short videos with trendy sounds and served up fresh to young eyes — has breathed life into trends like tooth gems. Celebrities such as Drake, Rihanna, and Bella Hadid wore them years ago. Now, some TikTok influencers are selling DIY gem kits.

But it doesn’t stop there. There are DIY tooth replacement kits and bedazzled grills available online for under $25, and recipes for homemade toothpaste and whitening treatments. The TikTok hashtag #DIYdentist has 2.6 million views. It’s enough to make any licensed dentist or orthodontist cringe.

The professionals wholeheartedly agree that DIY dentistry is a very bad idea. Dental care can be expensive, and orthodontic treatment is usually considered cosmetic and not covered by dental insurance — which 65 million Americans don’t have. And, according to the 2020 “Annual Review of Public Health” report, people who are low-income, uninsured, members of racial minority groups, immigrants, or living in rural areas are more likely to have poor oral health.

So, is the high cost of dental treatment driving these viral trends among young people, or is it the lure of supposedly painless, instantly changed smiles?

Dr. Ruchi Sahota, a Fremont, California, dentist and spokesperson for the American Dental Association, said she can understand why patients want to try DIY dentistry at home. “I just don’t know how [they] could do it safely,” she said, especially altering the shape of their teeth. While filing teeth is something a dentist might do to smooth out imperfections or create space between teeth during treatment for braces, for instance, some people are doing it themselves to smooth away chips in teeth or create vampire-like fangs for aesthetic reasons. “When we practice dentistry, we do it with the background information of years of training, X-rays, and the experience that helps us decide when and how to do the treatment,” Sahota said.

Even tooth gems applied correctly with oral bonding materials are troublesome, she said, because they “are adding something to your teeth that will also attract bacteria. You’re increasing your risk of cavities, of gum infections. And you’re increasing your risk of chipped teeth, of inflammation inside your mouth.”

DIY prices are certainly part of the allure. On Amazon, a 25-piece tooth gem kit was selling for $12.99 from Tondiamo, a brand that also sells children’s earwax removal tools, waterproof adhesive bandages, and chainsaw chains. The kit comes with 10 rhinestones, a mini-LED keychain to cure the adhesive, four wooden sticks, five disposable applicator brushes, and five cotton rolls.

But no instructions.

Reviews on Amazon complained of the gems not sticking. Some suggested using nail glue — which is toxic and can damage tooth enamel. But among Amazon’s “frequently bought together” suggestions: a bottle of epoxy resin glue.

A gold-plated, single-tooth grill front for $7.98 from TCOTBE and a set of silver-plated, brass fronts for $10.99 from OOCC both advertised that “one size fits most,” but reviewers said otherwise. “Save your money and use foil (old school way) if you want a grill lol,” one buyer warned. Bleeding gums were a common complaint among the reviewers.

Perhaps the most bizarre DIY find was a temporary tooth repair kit for under $25 from CZsy. It came with plastic “veneers” in different shapes for missing teeth, and moldable plastic beads for repairs.

It also did not come with printed instructions, but these were buried in the product description on Amazon’s site:

1. Drop into hot water above 130 degrees for about two minutes.
2. Shape the size what you want.

No company information or websites could be found for some of these brands, but the products had one thing in common: a bar code sticker reading “Made in China.” Instead of responding to a request by KHN for an explanation of its policies, Amazon removed the listing for replacement teeth. The other items were still available to order at publication time.

It’s not just DIY dentistry giving licensed professionals a toothache. Vendors touting certificates to apply composite veneers and partials — dentures that replace missing teeth when someone still has multiple natural teeth in place — are sprouting up on social media. Vendors like Marie’s Beauty Bar in Philadelphia will apply composite veneers over less-than-perfect smiles — in this case, starting at $1,999 per hour with a $499 deposit — as a lower-cost alternative to porcelain veneers, which require shaving down the natural teeth. The merchant advertises veneer training for $5,999. Marie’s Beauty Bar did not respond to emails or voice messages seeking comment.

DIY dentistry isn’t just a phenomenon of young people on social media. “There are teens, adolescents, even adults that are trying these things,” said Dr. Amber Bonnaig, a dentist in Marietta, Georgia, and a state director for DentaQuest, a Boston company. “A major contributing factor is lack of access to dental care.”

DIY can appear a viable alternative, especially since a person with severely damaged teeth, in severe pain, or with mounting dental bills from repairing DIY damage rarely displays the disappointing results on TikTok. Social media users, for the most part, display carefully curated highlights, not adverse reactions.

“The ‘cool thing’ right now is all these hacks to make things supposedly easier or more accessible,” she said. Caveat emptor, or let the buyer beware, she cautioned. Reviews from influencers who often receive free services in exchange for promotional posts may be biased. Bonnaig warned that complications could occur many days, weeks, or months after treatment.

Even when people aren’t daring to drill their own teeth, they can do damage with other social trends like drinking “healthy Coke,” a concoction of balsamic vinegar — which has a higher acid content than the actual soft drink — and flavored carbonated water. It’s a recipe for severe erosion of tooth enamel.

Such low-cost hacks may end up costing patients far more in the long run. Sahota suggested that consumers looking for safe ways to enhance their smiles can scour the products on the Mouth Healthy site that sports the ADA seal of acceptance. Bonnaig and Sahota both implore patients to discuss their oral and cosmetic concerns with a dentist.

Every tooth and every mouth is unique, and there is no safe one-size-fits-all DIY hack. “You can have a beautiful smile,” Sahota said, “even if it’s not perfect.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

I woke up in a strange bedroom with 24 electrodes glued all over my body and a plastic mask attached to a hose covering my face.

The lab technician who watched me all night via video feed told me that I had “wicked sleep apnea” and that it was “central sleep apnea” — a type that originates in the brain and fails to tell the muscles to inhale.

As a journalist — and one terrified by the diagnosis — I set out to do my own research. After a few weeks of sleuthing and interviewing experts, I reached two important conclusions.

First, I had moderate apnea, if that, and it could be treated without the elaborate machines, mouthpieces, or other devices that specialists who had consulted on my care were talking about.

Second, the American health care system has joined with commercial partners to define a medical condition — in this case, sleep apnea — in a way that allows both parties to generate revenue from a multitude of pricey diagnostic studies, equipment sales, and questionable treatments. I was on a conveyor belt.

It all began with a desire for answers: I had been feeling drowsy during the day, and my wife told me I snored. Both can mean obstructive sleep apnea. With obstructive sleep apnea, the mouth and throat relax when a person is unconscious, sometimes blocking or narrowing the airway. That interrupts breathing, as well as sleep. Without treatment, the resulting disruption in oxygen flow might increase the risk of developing certain cardiovascular diseases.

So I contacted a sleep-treatment center, and doctors gave me an at-home test ($365). Two weeks later, they told me I had “high-moderate” sleep apnea and needed to acquire a continuous positive airway pressure, or CPAP, machine, at a cost of about $600.

Though I had hoped to get the equipment and adjust the settings to see what worked best, my doctors said I had to come to the sleep lab for an overnight test ($1,900) to have them “titrate” the optimal CPAP air pressure.

“How do you treat central sleep apnea?” I worriedly asked the technician after that first overnight stay. She said something about an ASV (adaptive servo-ventilation) machine ($4,000). And one pricey lab sleepover wasn’t enough, she said. I needed to come back for another.

(Most procedures and devices mentioned in this article were covered or would have been covered by insurance — in my case, Medicare, plus a supplemental plan. Unnecessary care is a big reason Americans’ insurance costs — premiums, copays, and deductibles — tend to rise year after year.)

As a journalist who spent years covering the business of health care, I found there was more motivating my expensive testing cascade than concerns about my health.

The American Academy of Sleep Medicine, or AASM, a nonprofit based near Chicago, decides what is sleep apnea and how to treat it. Working with sleep societies around the world, it publishes the International Classification of Sleep Disorders, relied on by doctors everywhere to diagnose and categorize disease.

But behind that effort lie considerable conflicts of interest. Like so much of U.S. health care, sleep medicine turns out to be a thriving industry. AASM finances its operations in part with payments from CPAP machine manufacturers and other companies that stand to profit from expensive treatments and expansive definitions of apnea and other sleep disorders.

Zoll Itamar, which makes the at-home testing device I used, as well as implantable nerve-stimulation hardware for central sleep apnea, is a $60,000, “platinum” partner in AASM’s Industry Engagement Program. So is Avadel Pharmaceuticals, which is testing a drug to treat narcolepsy, characterized by intense daytime sleepiness.

Other sponsors include the maker of an anti-insomnia drug; another company with a narcolepsy drug; Fisher & Paykel Healthcare, which makes CPAP machines and masks; and Inspire Medical Systems, maker of a heavily advertised surgical implant, costing tens of thousands of dollars, to treat apnea.

Corporate sponsors for Sleep 2022, a convention AASM put on in Charlotte, North Carolina, with other professional societies, included many of those companies, plus Philips Respironics and ResMed, two of the biggest CPAP machine makers.

In a statement, AASM spokesperson Jennifer Gibson said a conflict-of-interest policy and a non-interference pledge from industry funders protect the integrity of the academy’s work. Industry donations account for about $170,000 of AASM’s annual revenue of about $15 million, she said. Other revenue comes from educational materials and membership and accreditation fees.

Here’s what else I found. Almost everybody breathes irregularly sometime at night, especially during REM sleep, characterized by rapid eye movement and dreams. Blood oxygen levels also fluctuate slightly.

But recent European studies have shown that standards under the International Classification of Sleep Disorders would doom huge portions of the general population to a sleep apnea diagnosis — whether or not people had complaints of daytime tiredness or other sleep problems.

A study in the Swiss city of Lausanne showed that 50% of local men and 23% of the women 40 or older were positive for sleep apnea under such criteria.

Such rates of disease are “extraordinarily high,” “astronomical,” and “implausible,” Dr. Dirk Pevernagie, a scientist at Belgium’s Ghent University Hospital, wrote with colleagues two years ago in a comprehensive study in the Journal of Sleep Research.

“Right now, there is no real evidence for the criteria that have been put forward to diagnose obstructive sleep apnea and rate its severity,” he said in an interview.

Likewise, 19% of middle-aged subjects in a 2016 Icelandic study appeared to have moderate to severe “apnea” under one definition in the International Classification of Sleep Disorders even though many reported no drowsiness.

“Most of them were really surprised,” said Erna Sif Arnardóttir, who led the study and is running a large European program to refine detection and treatment of apnea.

Nevertheless, the official AASM journal recommends extremely broad screening for sleep apnea, looking for patients who have what it defines as illness. Everybody 18 and older should be screened every year for apnea if they have diabetes, obesity, untreated high blood pressure, or heart disease — even if they have never complained about sleep problems, the group says.

AASM “continually evaluates the definitions, criteria and recommendations used in the identification of sleep apnea and other sleep disorders,” Gibson said in the statement. Meanwhile, routine screening by primary care doctors “is a simple way” of gauging whether a high-risk patient may have obstructive sleep apnea, the statement said.

The U.S. Preventive Services Task Force, an authoritative body that reviews the effectiveness of preventive care, takes a conservative view, more like that of the European researchers, concluding there is “insufficient” evidence to support widespread screening among patients with no symptoms.

Many insurers refuse to pay for CPAP machines and other treatments prescribed for people at the outer edges of the AASM’s apnea definition. But AASM is pressuring them to come around.

After all my reporting, I concluded that my apnea is real, though moderate. My alarming reading in the overnight lab — diagnosed quickly as central sleep apnea — was a byproduct of the testing machinery itself. That’s a well-described phenomenon that occurs in 5% to 15% of patients.

And when I looked closely at the results of my at-home diagnostic test, I had an epiphany: My overall score was 26 breathing interruptions and blood-oxygen level declines, on average, per hour — enough to put me in the “high-moderate” category for apnea. But when I looked at the data sorted according to sleeping positions, I saw that I scored much better when I slept on my side: only 10 interruptions in an hour.

So I did a little experiment: I bought a $25 pulse oximeter with a smartphone app that records oxygen dips and breathing interruptions. When I slept on my side, there were hardly any.

Now I sleep on my side. I snore less. I wake up refreshed. I’m not daytime drowsy.

None of my specialists mentioned turning on to my side — known in medical parlance as “positional therapy” — though the intervention is recognized as effective by many researchers. Sleeping on one’s back contributes to snoring and blockages, especially as people age and the muscles in the throat become looser.

“Positional patients … can sleep in the lateral position and sleep quite well,” said Arie Oksenberg, a sleep researcher formerly at Loewenstein Hospital in Israel.

But it’s not easy to find this in the official AASM treatment guidelines, which instead go right to the money-making options like CPAP machines, surgery, central apnea, and mouth appliances.

Dealing with apnea by shifting slightly in bed gets little more than a couple of paragraphs in AASM’s guideline on “other” treatments and a little box on a long and complex decision chart.

A third or more of patients wear CPAPs only a few hours a night or stop using them. It turns out people don’t like machines in their beds.

“Positional therapy is an effective treatment option for some patients,” said the AASM’s Gibson. But she said there are concerns about whether patients will sleep on their sides long term and whether trying to stay in one position might cause sleep interruptions itself.

It’s true that side-sleeping doesn’t help everybody. And it often takes practice. (Some people tape a tennis ball to their pajamas to keep them off their backs.) Even conservative sleep doctors say CPAP machines are the best solution for many patients.

But there is a largely overlooked alternative.

“Are we missing a simple treatment for most adult sleep apnea patients?” was the name of a 2013 paper that Oksenberg and a colleague wrote about positional therapy.

In my case, the answer was “yes.”

Jay Hancock is a former KHN senior correspondent.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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President Joe Biden caused a stir in a “60 Minutes” interview on Sept. 18 when he declared that the COVID-19 pandemic is over.

“We still have a problem with COVID — we’re still doing a lot of work on it,” Biden said. “But the pandemic is over.”

Critics countered that the U.S. is still averaging about 400 deaths daily from the virus, that nearly 30,000 Americans remain hospitalized, and that many others are suffering from “long COVID” symptoms stemming from previous infections.

Two days later, Biden acknowledged that despite the negative reactions by some, the pandemic “basically is not where it was.” White House press secretary Karine Jean-Pierre called the coronavirus “a lot more manageable.” Past experience means “we know what works,” she said.

PolitiFact has been tracking a campaign promise Biden made in 2020 that is closely related, but distinct, from what Biden told “60 Minutes.” During the presidential campaign, Biden said, “I’m never going to raise the white flag and surrender. We’re going to beat this virus. We’re going to get it under control, I promise you. “

Biden is on safer linguistic ground with his promise to get COVID “under control” than saying “the pandemic is over.”

There remains some debate among public health experts about whether the pandemic is “over” — or whether it realistically can ever be. There is no official arbiter for making that decision, and the word “over” suggests a finality that is not well suited for describing a pathogen that will exist in some form indefinitely.

However, we found broad agreement among infectious-disease specialists that the pandemic by now is “under control.”

When Biden was inaugurated, physical distancing was widely enforced, schools were often virtual, public events were rare or tightly controlled, and few Americans had yet received a vaccine. Today, life for many Americans is much closer to the pre-pandemic norm, with virtually all schools open, concerts and restaurants well attended, and travel back to its typical level.

“The nation clearly has made tremendous progress on COVID-19 since President Biden’s election,” said Jen Kates, senior vice president and director of global health and HIV policy at KFF. “I would probably say that we are in a pandemic ‘transition’ phase — that is, moving from the pandemic into a post-pandemic period. But this is a continuum, not a cliff, where it’s a pandemic one day and over the next,” Kates added.

Dr. Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials, added that the promise to get the pandemic under control “is certainly well on course, or perhaps even met, as far as what the federal government can provide to accomplish that.”

And Dr. William Schaffner, a professor of preventive medicine and health policy at Vanderbilt University, agreed that the “emergent phase of the pandemic is coming to a close. We’re now moving into the ongoing struggle — call it a truce with the virus.”

Medical experts said pandemics inevitably become “endemic,” meaning that the pathogen is here to stay but does not present a widespread emergency.

“We will always have to manage COVID in the medical system,” said Dr. Monica Gandhi, a professor of medicine at the University of California-San Francisco. “Unfortunately, although we can bring down deaths to very low, I don’t think we will ever get to zero deaths from COVID-19.”

The level of U.S. deaths from COVID is lower today than it has been during most of the pandemic, and it has been that way since the spring.

Notably, the number of “excess deaths” is also down. That’s a metric that gauges how many more deaths are occurring beyond the long-term average for that time of year. The number of excess deaths nationally per week has been consistently between zero and 5,000 since the spring, after peaking at 20,000 to 25,000 per week during four previous surges since the pandemic began.

Hospitalization has held steady recently at some of the lowest rates of the pandemic. And even this level may overstate the virus’s impact; routine testing upon admission often detects cases that are asymptomatic and largely coincidental to the reason a patient is admitted.

Gandhi pointed to data from Massachusetts hospitals showing that most hospitalized patients who test positive for COVID have only “incidental infections,” with only 1 in 3 being treated primarily for a COVID-related illness.

Experts noted that hospitalizations and deaths, even at these reduced levels, remain too high, and they cautioned that infections could increase as winter forces people indoors. Still, they credit the availability of vaccines and therapeutics, as well as the knowledge gained from living with the virus for more than two years, for the likelihood that the darkest days of the pandemic are behind us.

“I am not worried at all that we will go back to the scale of hospitalizations and deaths of the worst days of the pandemic,” said Brooke Nichols, an infectious-disease mathematical modeler and health economist at the Boston University School of Public Health. “We will likely enter into a seasonal COVID vaccine situation, potentially combined alongside the flu into the same vaccine, and these seasonal vaccines will become critical to avoiding hospitalizations and deaths during the flu and COVID seasons.”

There has been no major new variant since omicron emerged in late 2021, and even the most recent omicron subvariant to emerge, BA.5, has had a long run as the dominant strain in the U.S., prevailing since early July.

This doesn’t mean that a more dangerous new strain couldn’t emerge. However, public health experts take comfort from recent patterns. The trend during most of 2022 suggests that a rapid succession of ever-more-confounding — and vaccine-evading — variants is not inevitable. If a major new variant does emerge, mRNA vaccines like those made by Moderna and Pfizer-BioNTech can be updated fairly easily for it.

Vaccination uptake, though, remains an urgent question. About one-third of Americans are not fully vaccinated, and an even smaller percentage have received boosters. Plescia said “the main deciding factor right now is not going to be the president or the response of the federal government — it’s going to be the response of the public.”

“I think there’s disease fatigue and vaccine fatigue and wearing-a-mask fatigue,” said Dr. Georges Benjamin, executive director of the American Public Health Association. “People are just tired of COVID and trying to wish it away, and it’s unfortunate because it’s not gone. We’re tired of it, but it’s not tired of us yet.”

Some experts caution that a pandemic “under control” doesn’t mean the costs will be minimal.

“The degree of protection afforded by the current vaccines available, especially to the most vulnerable, is of limited duration, and nonfatal outcomes from COVID can still have knock-on consequences to the population health,” said Babak Javid, an associate professor in the division of experimental medicine at UCSF.

These consequences are called “long COVID” and nearly 1 in 5 Americans who have had COVID are suffering from it. The Centers for Disease Control and Prevention defines long COVID as symptoms lasting three or more months after contracting the virus that weren’t experienced before.

“Under control” suggests progress on keeping further spread within modest limits. It does not mean that people haven’t lost loved ones or felt continuing effects from the virus; clearly, they have.

What Does Biden Still Need to Do?

Biden and his administration still have work to do, experts said.

Gandhi said the federal government should do a better job targeting boosters and therapeutics at populations most at risk of severe breakthrough infections, notably older Americans and people who are immunocompromised.

And Schaffner urged more effective and unified messaging, with efforts to remove any hints of politics. “I wish the federal government would get together on who the main messenger is, and provide sustained, clear, simple messages,” he said.

Biden may not have used the most appropriate word when he described the pandemic as “over,” but the long-term statistical trends have been trending in the right direction, and the vaccines and treatments should dampen the severity of future waves. For these reasons, experts say it’s fair to declare that the pandemic is “under control.” If circumstances change, we will reassess our rating, but for now, this receives a Promise Kept.

McClintock, the wife of U.S. Rep. Tom McClintock (R-Calif.), died suddenly in December from dehydration due to gastroenteritis — an inflammation of the stomach and intestines — that was caused by “adverse effects of white mulberry leaf ingestion,” according to a report from the Sacramento County coroner. The coroner ruled the death an accident.

But Sacramento County Coroner Kimberly Gin has not explained — nor provided records that explain — why she determined white mulberry leaf led to the dehydration that killed McClintock at age 61, fueling skepticism among a variety of experts.

RELATED: Mulberry leaves blamed for death of California congressman’s wife

A “partially intact” white mulberry leaf was found in Lori McClintock’s stomach, according to the autopsy report. But there is no other reference to her use of white mulberry leaves, supplements, extracts, powders — or any other method of ingesting the plant — in the documents the coroner’s office has released relating to the case.

“It would take literally bushel baskets of white mulberry leaves to cause some type of untoward effect. And even then, you don’t see anything lethal,” said Bill Gurley, principal scientist at the University of Mississippi’s National Center for Natural Products Research, which collaborates with academic, government, and industry officials to research and develop natural products.

Gurley, an expert in herb and drug interactions, called white mulberry leaf — which has been used for a variety of ailments, including diabetes, high blood pressure, and obesity — “probably one of the safest leaves in the world” and said “its track record for safety is unsurpassed.”

“I’m just scratching my head as to how in the world they could jump to the conclusion that this lady passed away by ingesting, at least as far as we know, only one mulberry leaf,” he said.

Dr. Mary Hardy, who founded the integrative medicine clinic at Cedars-Sinai Medical Center in Los Angeles and researched the safety of some alternative medicines and therapies for the now-closed UCLA Center for Dietary Supplements Research in Botanicals, said the coroner’s conclusion is “not convincing.”

“The proximate cause of death is not supported” by the available records, Hardy said.

Gin, contacted through Sacramento County spokesperson Kim Nava, repeatedly declined interview requests from KHN and has refused to provide information that explains how her office concluded that a partial white mulberry leaf contributed to McClintock’s death.

The leaves and fruit of the white mulberry tree, native to China, have been used for centuries in traditional medicine. Academic studies over the past decade have found that the extract from its leaves can lower blood sugar levels and help with weight loss. People take it in capsule or pill form, as an extract or powder. They can also eat the young leaves raw or brew leaves as an herbal tea.

It’s unclear how McClintock ingested the white mulberry leaf — whether she ate it raw or drank it in a tea — and where she got it.

Tom McClintock, a Republican who represents a district that spans multiple counties in central and Northern California, found his wife unresponsive at their Elk Grove, California, home on Dec. 15, 2021, according to the coroner’s report. He has not responded to repeated requests for comment.

At his wife’s funeral in January, Tom McClintock told mourners she was fine when he spoke with her the day before she died. But according to the coroner’s report, the day before her death “she had complaints of an upset stomach.”

McClintock also told mourners that “she was carefully dieting” and that “she just joined a gym.”

KHN obtained the coroner’s report, dated March 10, in addition to the autopsy report and death certificate, in July and reported the findings in August.

The coroner’s office tested McClintock’s body for the flu, other respiratory viruses, and covid-19. None were detected. It also commissioned independent lab tests that showed McClintock’s body had elevated levels of urea nitrogen, sodium, and creatinine — all signs of dehydration, according to five pathologists interviewed by KHN. Just one of them said it was plausible that white mulberry leaf could have contributed to the dehydration.

All the pathologists said that the coroner’s publicly released documents didn’t provide a complete picture of how McClintock died and that it didn’t include key details such as what the coroner’s office found at the house, and whether McClintock might have been taking any medications or supplements.

“The indication that there may be some dehydration is true. They don’t really have much else to go with,” said Dr. Gregory G. Davis, director of the forensic division of the University of Alabama-Birmingham’s Department of Pathology and chief coroner-medical examiner for Jefferson County, Alabama.

“I don’t know that mulberry leaf necessarily played any role in the death,” Davis said, adding, as other experts did, that it’s not considered toxic.

“She seemed, looking at her autopsy results, like she was reasonably healthy, and you wouldn’t have really expected her to die at this time. So that’s already made it a difficult case because it’s not obvious.”

Dr. James Gill, chair of the College of American Pathologists’ Forensic Pathology Committee and chief medical examiner of Connecticut, added it can take days for someone to die of dehydration. One leaf alone, which hadn’t been fully digested, a process that usually takes only a couple of hours, would not “have contributed to death,” he said.

“It takes about at least a week or so for someone to die from not drinking from dehydration,” Gill said. Based on the available records, “there are some things that really don’t fit.”

Gill said he would have ruled McClintock’s death a natural death of unknown causes, which happens in about 5% of his death investigations.

No deaths from the white mulberry plant have been reported to poison control officials in the past 10 years, according to the American Association of Poison Control Centers. Two cases of people who may have been sickened by mulberry supplements have been reported to the FDA since 2002, according to its database that tracks “adverse events.” FDA spokesperson Lindsay Haake declined to say whether the agency is looking into the case because it does not disclose investigations.

After KHN broke the story about McClintock’s cause of death, the coroner’s office released a couple of additional documents, including a Dec. 29, 2021, letter from Alison Colwell, curator of the University of California-Davis Center for Plant Diversity. The coroner had asked Colwell to identify the 1 1/8-inch-by-1 7/8-inch leaf fragment found in McClintock’s stomach during the autopsy.

Colwell identified it as white mulberry and concluded, based on its flexibility and “some green color,” that it “was likely ingested when fresh,” her letter said.

Although white mulberry trees are common in the Sacramento region, she noted that their leaves in December are “tough, yellowing and have mostly fallen off of the trees.”

Colwell also stated simply: “White mulberry is not toxic.”

“I compared the specimen to lethally toxic species that are known to be planted or are native in the Sacramento area and found no matches,” her letter said. Colwell declined an interview request.

The herbal products industry, the dietary supplements industry, and their allies have chafed at the possibility that McClintock may have died after ingesting supplements containing white mulberry leaf — let alone a white mulberry leaf itself.

“It’s been used as a food, used as a medicine,” said Rick Kingston, a clinical professor at the University of Minnesota’s College of Pharmacy. He’s also co-founder of SafetyCall International, a company that helps the supplements industry and other clients log and track adverse events related to their products.

Several plant specialists also question whether the leaf found in McClintock’s stomach was white mulberry. Élan Sudberg, CEO of California-based Alkemist Labs, which conducts botanical plant testing for the supplements industry and other clients, said Colwell’s letter lacks details of her assessment of the leaf that would help others reading the report definitively identify it as white mulberry. Either that, he said, or the leaf wasn’t white mulberry.

He said the coroner should release more information, reopen the case, and conduct more rigorous tests.

“I’d love to see a reexamination and understand why they went to the conclusion that she died from a basically inert leaf,” Sudberg said.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Like past COVID waves, this one will leave a lingering imprint in the form of long COVID, an ill-defined catchall term for a set of symptoms that can include debilitating fatigue, difficulty breathing, chest pain, and brain fog.

Although omicron infections are proving milder overall than those caused by last summer’s delta variant, omicron has also proved capable of triggering long-term symptoms and organ damage. But whether omicron causes long COVID symptoms as often — and as severe — as previous variants is a matter of heated study.

Michael Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy, is among the researchers who say the far greater number of omicron infections compared with earlier variants signals the need to prepare for a significant boost in people with long COVID. The U.S. has recorded nearly 38 million COVID infections so far this year, as omicron has blanketed the nation. That’s about 40% of all infections reported since the start of the pandemic, according to the Johns Hopkins University Coronavirus Research Center.

Long COVID “is a parallel pandemic that most people aren’t even thinking about,” said Akiko Iwasaki, a professor of immunobiology at Yale University. “I suspect there will be millions of people who acquire long COVID after omicron infection.”

Scientists have just begun to compare variants head to head, with varying results. While one recent study in The Lancet suggests that omicron is less likely to cause long COVID, another found the same rate of neurological problems after omicron and delta infections.

Estimates of the proportion of patients affected by long COVID also vary, from 4% to 5% in triple-vaccinated adults to as many as 50% among the unvaccinated, based on differences in the populations studied. One reason for that broad range is that long COVID has been defined in widely varying ways in different studies, ranging from self-reported fogginess for a few months after infection to a dangerously impaired inability to regulate pulse and blood pressure that may last years.

Even at the low end of those estimates, the sheer number of omicron infections this year would swell long-COVID caseloads. “That’s exactly what we did find in the UK,” said Claire Steves, a professor of aging and health at King’s College in London and author of the Lancet study, which found patients have been 24% to 50% less likely to develop long COVID during the omicron wave than during the delta wave. “Even though the risk of long COVID is lower, because so many people have caught omicron, the absolute numbers with long covid went up,” Steves said.

A recent study analyzing a patient database from the Veterans Health Administration found that reinfections dramatically increased the risk of serious health issues, even in people with mild symptoms. The study of more than 5.4 million VA patients, including more than 560,000 women, found that people reinfected with COVID were twice as likely to die or have a heart attack as people infected only once. And they were far more likely to experience health problems of all kinds as of six months later, including trouble with their lungs, kidneys, and digestive system.

“We’re not saying a second infection is going to feel worse; we’re saying it adds to your risk,” said Dr. Ziyad Al-Aly, chief of research and education service at the Veterans Affairs St. Louis Health Care System.

Researchers say the study, published online but not yet peer-reviewed, should be interpreted with caution. Some noted that VA patients have unique characteristics, and tend to be older men with high rates of chronic conditions that increase the risks for long COVID. They warned that the study’s findings cannot be extrapolated to the general population, which is younger and healthier overall.

“We need to validate these findings with other studies,” said Dr. Harlan Krumholz, director of the Yale New Haven Hospital Center for Outcomes Research and Evaluation. Still, he added, the VA study has some “disturbing implications.”

With an estimated 82% of Americans having been infected at least once with the coronavirus as of mid-July, most new cases now are reinfections, said Justin Lessler, a professor of epidemiology at the University of North Carolina Gillings School of Global Public Health.

Of course, people’s risk of reinfection depends not just on their immune system, but also on the precautions they’re taking, such as masking, getting booster shots, and avoiding crowds.

New Jersey salon owner Tee Hundley, 43, has had COVID three times, twice before vaccines were widely available and again this summer, after she was fully vaccinated. She is still suffering the consequences.

After her second infection, she returned to work as a cosmetologist at her Jersey City salon but struggled with illness and shortness of breath for the next eight months, often feeling like she was “breathing through a straw.”

She was exhausted, and sometimes slow to find her words. While waxing a client’s eyebrows, “I would literally forget which eyebrow I was waxing,” Hundley said. “My brain was so slow.”

When she got a breakthrough infection in July, her symptoms were short-lived and milder: cough, runny nose, and fatigue. But the tightness in her chest remains.

“I feel like that’s something that will always be left over,” said Hundley, who warns friends with COVID not to overexert. “You may not feel terrible, but inside of your body there is a war going on.”

Although each omicron subvariant has different mutations, they’re similar enough that people infected with one, such as BA.2, have relatively good protection against newer versions of omicron, such as BA.5. People sickened by earlier variants are far more vulnerable to BA.5.

Several studies have found that vaccination reduces the risk of long COVID. But the measure of that protection varies by study, from as little as a 15% reduction in risk to a more than 50% decrease. A study published in July found the risk of long COVID dropped with each dose people received.

For now, the only surefire way to prevent long COVID is to avoid getting sick. That’s no easy task as the virus mutates and Americans have largely stopped masking in public places. Current vaccines are great at preventing severe illness but do not prevent the virus from jumping from one person to the next. Scientists are working on next-generation vaccines — “variant-proof” shots that would work on any version of the virus, as well as nasal sprays that might actually prevent spread. If they succeed, that could dramatically curb new cases of long COVID.

“We need vaccines that reduce transmission,” Al-Aly said. “We need them yesterday.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

SACRAMENTO  — California is trying to ease the pain of vasectomies by making them free for millions of residents.

Federal law and state law require most health insurers to cover prescription contraceptives at no cost to the patient. But those provisions apply to only 18 FDA-approved birth control options for women, so anyone with testicles is out of luck.

California lawmakers are now considering a bill that would expand that requirement to male sterilization and non-prescription birth control, including condoms and contraceptive sponges. If the Contraceptive Equity Act of 2022 passes, commercial insurance plans regulated by the state won’t be allowed to impose out-of-pocket costs, like copays, coinsurance, and deductibles, on those modes of birth control.

“It’s pretty groundbreaking in that way — it’s a whole new framework to think about contraception as something that is relevant for people of all genders,” said Liz McCaman Taylor, a senior attorney with the National Health Law Program, a group that advocates for the health rights of low-income people.

A vasectomy is an outpatient surgical procedure in which the patient’s supply of sperm is cut off from his semen by sealing or snipping the tubes that transport sperm from the testes to the penis. Most men need to recover on the couch with an ice pack for a day or two, and a test a few months later determines whether the procedure worked.

Because vasectomies are elective procedures and usually not urgent, price can be a deciding factor.

For Nathan Songne, cost was the most stressful part of the procedure. For several years, the 31-year-old had known he didn’t want to have kids biologically. Better to adopt a 4-year-old and skip the diaper stage, he thought. He was adopted by his stepfather as a child and knew he didn’t need to be genetically related to his children to love them.

“My only concern was that I had no idea how much it was going to cost me because nobody told me,” said Songne, who lives in Mission Viejo, in Orange County. If the procedure cost $1,000, as he expected, he wouldn’t be able to afford it, he said.

Songne’s insurance, which he gets through his work assembling guitars, covered 70% of the Aug. 8 procedure, leaving him with a bill of just under $200. “Cost did affect my decision, but because it was only $200, it made me feel a lot more relieved about continuing on with the vasectomy,” he said.

There are two hot times of year in the vasectomy business, according to Dr. Mary Samplaski, an associate professor of urology at the USC Keck School of Medicine. First, she sees an uptick during the March Madness college basketball tournament, when men choose to recover on the couch watching hoops.

The end of the year is also busy, she said, because many patients have finally met their annual insurance deductible and can afford the procedure.

Patients discuss out-of-pocket costs in about 20% of her vasectomy consultations. “It’s obviously a nerve-wracking procedure,” Samplaski said. “And on top of that, if your copay is high, there’s even less reason to want to do it.”

In April, Jacob Elert comparison-shopped for a vasectomy near his home in Sacramento because his health plan doesn’t cover the procedure. He had hoped to schedule one with his regular urologist, he said, but that would have come with a $1,500 price tag.

Instead, he found a chain of vasectomy clinics where he could get the procedure for $850. Three months later, a test confirmed the vasectomy was a success.

Elert has no regrets, but had price not been a factor, he would have preferred to go to his regular urologist. “That’s the doctor I trust,” Elert said. “But it was just way too expensive.”

In November, California voters will decide whether to lock rights to abortion and contraception into the state constitution. But Proposition 1 doesn’t address issues such as cost and coverage, said Amy Moy, a spokesperson for Essential Access Health, a group that runs California’s Title X family planning program.

“The constitutional amendment is kind of the long-term protection, and we are still working to reduce barriers for Californians on the short-term and day-to-day level regardless of their gender,” she said.

SB 523 has sailed through preliminary votes in the state legislature, which faces an end-of-August deadline to act on bills. If the measure passes, it would take effect in 2024, and California would join a handful of states that require plans they regulate to completely cover vasectomies or non-prescription birth control.

The California Association of Health Plans is still evaluating the measure, which may be amended in the final days of the legislative session. But the association generally opposes bills that require additional insurance benefits because they could lead to higher premiums, spokesperson Mary Ellen Grant said.

SB 523 applies to more than 14 million Californians who work for the state, have a student health plan through a university, or have state-regulated commercial health plans. They would become eligible to receive free over-the-counter birth control — such as emergency contraception, condoms, spermicide, and contraceptive sponges — in addition to vasectomies. The bill would not apply to the millions of Californians whose health insurance plans are regulated by the federal government.

“We kind of learned from the national experiment with covid over-the-counter tests that reimbursement wasn’t the best model,” she said. “If people can’t afford to pay out-of-pocket for it, they’re just not going to get it.”

The California Health Benefits Review Program, which analyzes legislation, projected that roughly 14,200 people with state-regulated commercial insurance would get vasectomies in California this year. Eliminating cost sharing would increase the number of vasectomies by 252 in the law’s first year, the program estimated.

It’s a small increase. But that, plus a jump in the use of other contraceptives covered by the bill, particularly condoms, could add up to a big reduction in unintended pregnancies. Roughly 12,300 unplanned pregnancies might be averted each year if the mandate takes effect, a reduction of more than 11%, according to the analysis.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

USE OUR CONTENT

This story can be republished for free (details).

SACRAMENTO  — California is trying to ease the pain of vasectomies by making them free for millions of residents.

Federal law and state law require most health insurers to cover prescription contraceptives at no cost to the patient. But those provisions apply to only 18 FDA-approved birth control options for women, so anyone with testicles is out of luck.

California lawmakers are now considering a bill that would expand that requirement to male sterilization and non-prescription birth control, including condoms and contraceptive sponges. If the Contraceptive Equity Act of 2022 passes, commercial insurance plans regulated by the state won’t be allowed to impose out-of-pocket costs, like copays, coinsurance, and deductibles, on those modes of birth control.

“It’s pretty groundbreaking in that way — it’s a whole new framework to think about contraception as something that is relevant for people of all genders,” said Liz McCaman Taylor, a senior attorney with the National Health Law Program, a group that advocates for the health rights of low-income people.

A vasectomy is an outpatient surgical procedure in which the patient’s supply of sperm is cut off from his semen by sealing or snipping the tubes that transport sperm from the testes to the penis. Most men need to recover on the couch with an ice pack for a day or two, and a test a few months later determines whether the procedure worked.

Because vasectomies are elective procedures and usually not urgent, price can be a deciding factor.

For Nathan Songne, cost was the most stressful part of the procedure. For several years, the 31-year-old had known he didn’t want to have kids biologically. Better to adopt a 4-year-old and skip the diaper stage, he thought. He was adopted by his stepfather as a child and knew he didn’t need to be genetically related to his children to love them.

“My only concern was that I had no idea how much it was going to cost me because nobody told me,” said Songne, who lives in Mission Viejo, in Orange County. If the procedure cost $1,000, as he expected, he wouldn’t be able to afford it, he said.

Songne’s insurance, which he gets through his work assembling guitars, covered 70% of the Aug. 8 procedure, leaving him with a bill of just under $200. “Cost did affect my decision, but because it was only $200, it made me feel a lot more relieved about continuing on with the vasectomy,” he said.

There are two hot times of year in the vasectomy business, according to Dr. Mary Samplaski, an associate professor of urology at the USC Keck School of Medicine. First, she sees an uptick during the March Madness college basketball tournament, when men choose to recover on the couch watching hoops.

The end of the year is also busy, she said, because many patients have finally met their annual insurance deductible and can afford the procedure.

Patients discuss out-of-pocket costs in about 20% of her vasectomy consultations. “It’s obviously a nerve-wracking procedure,” Samplaski said. “And on top of that, if your copay is high, there’s even less reason to want to do it.”

In April, Jacob Elert comparison-shopped for a vasectomy near his home in Sacramento because his health plan doesn’t cover the procedure. He had hoped to schedule one with his regular urologist, he said, but that would have come with a $1,500 price tag.

Instead, he found a chain of vasectomy clinics where he could get the procedure for $850. Three months later, a test confirmed the vasectomy was a success.

Elert has no regrets, but had price not been a factor, he would have preferred to go to his regular urologist. “That’s the doctor I trust,” Elert said. “But it was just way too expensive.”

In November, California voters will decide whether to lock rights to abortion and contraception into the state constitution. But Proposition 1 doesn’t address issues such as cost and coverage, said Amy Moy, a spokesperson for Essential Access Health, a group that runs California’s Title X family planning program.

“The constitutional amendment is kind of the long-term protection, and we are still working to reduce barriers for Californians on the short-term and day-to-day level regardless of their gender,” she said.

SB 523 has sailed through preliminary votes in the state legislature, which faces an end-of-August deadline to act on bills. If the measure passes, it would take effect in 2024, and California would join a handful of states that require plans they regulate to completely cover vasectomies or non-prescription birth control.

The California Association of Health Plans is still evaluating the measure, which may be amended in the final days of the legislative session. But the association generally opposes bills that require additional insurance benefits because they could lead to higher premiums, spokesperson Mary Ellen Grant said.

SB 523 applies to more than 14 million Californians who work for the state, have a student health plan through a university, or have state-regulated commercial health plans. They would become eligible to receive free over-the-counter birth control — such as emergency contraception, condoms, spermicide, and contraceptive sponges — in addition to vasectomies. The bill would not apply to the millions of Californians whose health insurance plans are regulated by the federal government.

“We kind of learned from the national experiment with covid over-the-counter tests that reimbursement wasn’t the best model,” she said. “If people can’t afford to pay out-of-pocket for it, they’re just not going to get it.”

The California Health Benefits Review Program, which analyzes legislation, projected that roughly 14,200 people with state-regulated commercial insurance would get vasectomies in California this year. Eliminating cost sharing would increase the number of vasectomies by 252 in the law’s first year, the program estimated.

It’s a small increase. But that, plus a jump in the use of other contraceptives covered by the bill, particularly condoms, could add up to a big reduction in unintended pregnancies. Roughly 12,300 unplanned pregnancies might be averted each year if the mandate takes effect, a reduction of more than 11%, according to the analysis.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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