Debra Prichard was a retired factory worker who was careful with her money, including what she spent on medical care, said her daughter, Alicia Wieberg. “She was the kind of person who didn’t go to the doctor for anything.”

That ended last year, when the rural Tennessee resident suffered a devastating stroke and several aneurysms. She twice was rushed from her local hospital to Vanderbilt University Medical Center in Nashville, 79 miles away, where she was treated by brain specialists. She died Oct. 31 at age 70.

One of Prichard’s trips to the Nashville hospital was via helicopter ambulance. Wieberg said she had heard such flights could be pricey, but she didn’t realize how extraordinary the charge would be — or how her mother’s skimping on Medicare coverage could leave the family on the hook.

Then the bill came.

The Patient: Debra Prichard, who had Medicare Part A insurance before she died.

Medical Service: An air-ambulance flight to Vanderbilt University Medical Center.

Service Provider: Med-Trans Corp., a medical transportation service that is part of Global Medical Response, an industry giant backed by private equity investors. The larger company operates in all 50 states and says it has a total of 498 helicopters and airplanes.

Total Bill: $81,739.40, none of which was covered by insurance.

What Gives: Sky-high bills from air-ambulance providers have sparked complaints and federal action in recent years.

For patients with private insurance coverage, the No Surprises Act, which went into effect in 2022, bars air-ambulance companies from billing people more than they would pay if the service were considered “in-network” with their health insurers. For patients with public coverage, such as Medicare or Medicaid, the government sets payment rates at much lower levels than the companies charge.

But Prichard had opted out of the portion of Medicare that covers ambulance services.

That meant when the bill arrived less than two weeks after her death, her estate was expected to pay the full air-ambulance fee of nearly $82,000. The main assets are 12 acres of land and her home in Decherd, Tennessee, where she lived for 48 years and raised two children. The bill for a single helicopter ride could eat up roughly a third of the estate’s value, said Wieberg, who is executor.

The family’s predicament stems from the complicated nature of Medicare coverage.

Prichard was enrolled only in Medicare Part A, which is free to most Americans 65 or older. That section of the federal insurance program covers inpatient care, and it paid most of her hospital bills, her daughter said.

But Prichard declined other Medicare coverage, including Part B, which handles such things as doctor visits, outpatient treatment, and ambulance rides. Her daughter suspects she skipped that coverage to avoid the premiums most recipients pay, which currently are about $175 a month.

Loren Adler, a health economist for the Brookings Institution who studies ambulance bills, estimated the maximum charge that Medicare would have allowed for Prichard’s flight would have been less than $10,000 if she’d signed up for Part B. The patient’s share of that would have been less than $2,000. Her estate might have owed nothing if she’d also purchased supplemental “Medigap” coverage, as many Medicare members do to cover things like coinsurance, he said.

Nicole Michel, a spokesperson for Global Medical Response, the ambulance provider, agreed with Adler’s estimate that Medicare would have limited the charge for the flight to less than $10,000. But she said the federal program’s payment rates don’t cover the cost of providing air-ambulance services.

“Our patient advocacy team is actively engaged with Ms. Wieberg’s attorney to determine if there was any other applicable medical coverage on the date of service that we could bill to,” Michel wrote in an email to KFF Health News. “If not, we are fully committed to working with Ms. Wieberg, as we do with all our patients, to find an equitable solution.”

The Resolution: In mid-February, Wieberg said the company had not offered to reduce the bill.

Wieberg said she and the attorney handling her mother’s estate both contacted the company, seeking a reduction in the bill. She said she also contacted Medicare officials, filled out a form on the No Surprises Act website, and filed a complaint with Tennessee regulators who oversee ambulance services. She said she was notified Feb. 12 that the company filed a legal claim against the estate for the entire amount.

Wieberg said other health care providers, including ground ambulance services and the Vanderbilt hospital, wound up waiving several thousand dollars in unpaid fees for services they provided to Prichard that are normally covered by Medicare Part B.

But as it stands, Prichard’s estate owes about $81,740 to the air-ambulance company.

The Takeaway: People who are eligible for Medicare are encouraged to sign up for Part B, unless they have private health insurance through an employer or spouse.

“If someone with Medicare finds that they are having difficulty paying the Medicare Part B premiums, there are resources available to help compare Medicare coverage choices and learn about options to help pay for Medicare costs,” Meena Seshamani, director of the federal Center for Medicare, said in an email to KFF Health News.

She noted that every state offers free counseling to help people navigate Medicare.

In Tennessee, that counseling is offered by the State Health Insurance Assistance Program. Its director, Lori Galbreath, told KFF Health News she wishes more seniors would discuss their health coverage options with trained counselors like hers.

“Every Medicare recipient’s experience is different,” she said. “We can look at their different situations and give them an unbiased view of what their next best steps could be.”

Counselors advise that many people with modest incomes enroll in a Medicare Savings Program, which can cover their Part B premiums. In 2023, Tennessee residents could qualify for such assistance if they made less than $1,660 monthly as a single person or $2,239 as a married couple. Many people also could obtain help with other out-of-pocket expenses, such as copays for medical services.

Wieberg, who lives in Missouri, has been preparing the family home for sale.

She said the struggle over her mother’s air-ambulance bill makes her wonder why Medicare is split into pieces, with free coverage for inpatient care under Part A, but premiums for coverage of other crucial services under Part B.

“Anybody past the age of 70 is likely going to need both,” she said. “And so why make it a decision of what you can afford or not afford, or what you think you’re going to use or not use?”

Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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South Dakota lawmakers want state officials to create an educational video to help doctors understand when they can end a pregnancy without risking prison time under the state’s near-total abortion ban.

It’s an example of how states are responding to the national controversy over what exceptions to abortion bans actually mean. Critics point to reports of women developing dangerous complications after hospitals in states with strict abortion laws refused to terminate their pregnancies.

South Dakota legislators are moving a bill that would direct the state Department of Health to work with the attorney general and health and legal experts to create educational material, including a video, and publish it on its website.

The legislation is the first of its kind in the country, according to Susan B. Anthony Pro-Life America, an anti-abortion group.

The bill says the video would explain how South Dakota law defines abortion. Republican Rep. Taylor Rehfeldt, who introduced the bill, said treatments for miscarriages or an ectopic pregnancy —when a fertilized egg implants outside the uterus — do not count as abortions, and therefore are allowed.

The video would also discuss conditions that can threaten the life or health of a pregnant woman, and the criteria that providers might use to decide the best course of treatment. Rehfeldt said she expects the video to address when these medical conditions may need to be treated with an abortion, including how sick a patient needs to become.

Rehfeldt, a nurse anesthetist with a personal history of high-risk pregnancies, said she introduced the bill after hearing from health care providers who want guidance about the state’s abortion law.

“They said that they were confused and not sure when they can intervene,” Rehfeldt said. “I think it’s important that we provide that clarification because we all want moms to be taken care of.”

South Dakota has one of the nation’s strictest laws, prohibiting abortions unless they’re needed to save the life of a woman. There are no exceptions for preventing serious injury to the mother or in cases of fatal fetal anomalies, rape, or incest. Providing an illegal abortion is a felony that can be punished with two years in prison.

The state also has high rates of infant and maternal mortality, especially among Native Americans. Some South Dakota women have already been harmed because of the law after they were denied or received delayed abortions, according to Amy Kelley, an obstetrician and gynecologist in Sioux Falls.

Rehfeldt is confident her bill will pass the Republican-controlled legislature because the proposal has support from the governor’s office, health department, one of the state’s largest hospital systems, and state and national anti-abortion groups.

Anti-abortion advocates support the bill even though some groups, such as the Charlotte Lozier Institute, say exceptions to abortion bans are already clear. The group says state laws use language such as “reasonable medical judgment,” terms that hospitals should understand since such standards are often used in malpractice cases.

“Abortion activists have spread the dangerous lie that pregnant women in states with pro-life laws cannot receive emergency care,” Kelsey Pritchard, a South Dakota-based official with Susan B. Anthony Pro-Life America — which is affiliated with the Lozier Institute — said in a news release. “This patently false allegation that is used to justify the abortion industry’s agenda for no limits on abortion is putting women’s lives in danger.”

But abortion rights advocates say many doctors are afraid to provide critical care because of vaguely worded exceptions to abortion bans. Many say the only way to protect providers and their patients’ health is to repeal bans.

Nisha Verma is an OB-GYN in Georgia, where abortion is generally banned once fetal cardiac activity can be detected, typically around six weeks. Verma, who has provided abortions, is also a spokesperson for the American College of Obstetricians and Gynecologists.

“I understand the desire to grasp for anything that helps us provide care for our patients,” Verma said. But “there’s no way that you can create a video that talks about any type of inclusive list of conditions where you can and can’t provide care.”

Several other states have tried to clarify exceptions to their bans, but the South Dakota bill is the most comprehensive, Pritchard said.

In Oklahoma, the attorney general’s office sent a memo on the subject to prosecutors and police. It said doctors should have “substantial leeway” to provide lifesaving abortions, and don’t need to wait until a patient is “septic, bleeding profusely, or otherwise close to death.” The memo also says doctors should be prosecuted only if there’s evidence of criminal intent or a pattern of similar behavior.

Kentucky’s attorney general wrote an advisory opinion on the topic; Louisiana’s health department published a rule listing “medically futile” fetal conditions that can legally justify an abortion. Texas lawmakers added protections for doctors who end ectopic pregnancies or pregnancies of patients whose water breaks too early for the fetus to survive. The legislation does not use the word “abortion,” and lawmakers eschewed publicity as they were passing it.

Texas’ Supreme Court, lawmakers, and several pro- and anti-abortion rights advocates have all asked the state’s medical board for more guidance. The board must respond by mid-March as to whether it will do so, according to the health care publication Stat.

Abortion rights supporters are divided about the value of supplying guidance on exceptions to the abortion law.

“I wish we weren’t having this conversation,” said South Dakota Rep. Oren Lesmeister, a Democrat. “I wish we wouldn’t have had the trigger law” that banned most abortions.

But given that the law does exist, Lesmeister decided to co-sponsor and vote for the bill in hopes it will help doctors and their patients.

Critics of the legislation include the ACLU of South Dakota, the regional Planned Parenthood organization, and the Justice through Empowerment Network, a South Dakota abortion fund.

Verma and Kelley, the obstetricians, said laws, videos, and other guidance can’t capture the complexity of when an abortion may be necessary.

For example, conditions that aren’t fatal on their own can become deadly when combined with other complications, they said. Then there’s the question of when situations become life-threatening, which can happen quickly in obstetrics.

“There’s not a line in the sand where someone goes from being totally fine to acutely dying,” Verma said.

Verma and Kelley said doctors use their own expertise but also take their patients’ views into account when responding to life-threatening situations. That’s because one patient who learns they have a 25% risk of dying might decide against continuing their pregnancy, while another might view it as a risk worth taking, they said.

Some patients are willing to die if it means their baby will live, Kelley said, and “we honor their choice even if we don’t always think that that’s the right choice.”

Rehfeldt said she understands the concerns outlined by Verma and Kelley. But she said her bill would give doctors and hospital attorneys confidence to distinguish between legal and illegal procedures.

“If you have an interpretation that’s coming from collaboration with the attorney general, as well as the pertinent medical professionals, as well as the current governor’s office, I don’t see how you would be worried about being charged with a crime,” Rehfeldt said.

Kelley said it’s difficult to feel assured by any abortion-related guidance from South Dakota government officials when it feels as if they don’t trust doctors. For example, she said, lawmakers required abortion providers to share information with patients that can be opinionated and misleading.

“So, it’s really hard for them to then say, ‘Oh, but trust us, you won’t get in trouble with this law, we’ll go with your judgment,’” Kelley said.

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SACRAMENTO, Calif. — California voters will decide March 5 whether to pump billions more dollars into combating the nation’s worst homelessness crisis, an investment Democratic Gov. Gavin Newsom argues will finally provide the housing and treatment so badly needed by tens of thousands of homeless people.

Newsom is spearheading Proposition 1, a $6.4 billion bond he says would fund 11,150 new beds and housing units for people living on the streets with untreated mental illness or addiction, and ongoing capacity for 26,700 additional outpatient appointments. It would also alter how $3 billion to $4 billion in existing annual tax funding for mental health services is spent, funneling a hefty portion of it into housing.

Many authorities on mental health and homelessness agree California desperately needs thousands more housing units and treatment beds to successfully attack the growing public health crisis. Health and law enforcement groups have lined up behind the initiative, as have the mayors of the state’s major cities.

Homelessness statistics in California have risen a staggering 20% since Newsom took office in 2019, to more than 180,000 people — 68% of them on the streets and not in shelters. The numbers are growing despite Newsom’s unprecedented investment of more than $20 billion in homelessness programs, plus billions more for health and social services.

Yet many of the front-line workers implementing Newsom’s initiatives fear that Proposition 1 would simply pour more money into a broken homelessness response system that is largely failing to house those in need.

Rather than focus on getting homeless people into mental health and addiction programs — and ultimately into housing — many caseworkers say they waste precious time and taxpayer dollars searching for their homeless clients after encampments have been cleared by state and local officials, a policy Newsom has encouraged, not only for the safety of homeless people but for those in surrounding neighborhoods.

Once they locate their clients, advocates must help them — often repeatedly — obtain food, clothing, and medication refills, and replace official government documents like birth certificates and IDs. “You can’t get housing without that stuff,” said Afton Francik, an outreach worker with the Sacramento-based nonprofit Hope Cooperative, which is implementing several of Newsom’s homelessness and mental health initiatives.

Perhaps the biggest challenge they face, outreach workers and case managers say, is rebuilding the trust that took time to establish — and which they say is essential to getting people into treatment and housing.

“It makes it so much harder to even find people or help them get into housing because you have to go back and repeat that work you already did,” Francik said.

Newsom says California has placed at least 71,000 people indoors — either in permanent or temporary housing — since he took office in 2019. State money flows to cities and counties, which have opened at least 15,000 housing units and 2,485 residential treatment beds, plus additional outpatient capacity, during his tenure.

Newsom has also revamped health programs to get people off the streets, including a massive $12 billion transformation of the state Medicaid health insurance program that provides some patients with housing and one-on-one case management services.

As he promotes Proposition 1, Newsom is calling for stricter enforcement, saying he feels a deep responsibility to keep California’s streets clean and safe, and to respond to growing neighborhood concerns about trash, mental illness, crime, and drugs. He has acknowledged that sweeps can traumatize homeless people but argues that local officials who receive state money to clear encampments are supposed to find shelter or treatment for those displaced.

Sacramento County Sheriff Jim Cooper, who supports Proposition 1, said sweeps are sometimes necessary for public health and safety.

“This is a huge drain on public resources and emergency services,” Cooper said. “Drugs are everywhere. There is so much mental illness. We’ve got to get these folks the help and treatment they need.”

But critics of the sweeps argue that it’s inhumane to forcibly move people without providing shelter or housing. “We’re seeing a ton of enforcement, but there’s literally nowhere to put people,” said Crystal Sanchez, president of the Sacramento Homeless Union.

Newsom acknowledged the state doesn’t have enough housing for everyone who needs it, and that Proposition 1 is part of the solution. The measure would expand his existing housing and treatment programs, which do not trigger the land use and environmental reviews that often delay or kill new projects.

“We are in a unique position to take what we have been promoting — these promises — and make them real,” Newsom said in January.

Like all of Newsom’s homeless housing initiatives, Proposition 1 would rely on outreach teams and caseworkers to help homeless people obtain services and housing.

But in boots-on-the-ground interviews from rural Northern California to San Diego, such workers said it would be difficult to get more people into housing if they must continue picking up the pieces after encampment clearings — a policy the U.S. Supreme Court will scrutinize in April.

The question the court will consider is whether to allow criminal or civil penalties against homeless people living outdoors if no shelter or housing is available. Newsom said in an amicus brief that cities and counties should be allowed to clear encampments, signaling he has no plans to retreat from the policy.

“When encampments are being cleared by law enforcement, it totally upends people’s lives and violates that trust in a way that they’re going to be more resistant to help,” said Hannah Wesolowski, chief advocacy officer for the National Alliance on Mental Illness, whose California chapter supports the ballot initiative. “If someone has a mental illness and is unhoused, trust is the most important thing in trying to engage them in treatment and actually getting them into housing.”

Take Samuel Buckles, a longtime Sacramento resident who said he struggles with mental health and is addicted to fentanyl. Buckles, 53, lost his home in a fire and then his job early in the covid-19 pandemic. Since then, he has worked odd jobs as a handyman and purchased a recreational vehicle that he parked around Sacramento and called home.

When law enforcement officials cleared his camp in early February, they confiscated his RV because he had allowed the registration to lapse. He lost his birth certificate and Social Security card, all his medications for diabetes and high blood pressure, his extra clothing, and a fridge packed with groceries he’d recently purchased with his food stamp benefits.

“That was my home and everything I had in the world,” Buckles said on a cold February morning from his new form of shelter: a tent donated by outreach workers.

It was the first time in years he said he had truly felt homeless.

In mid-February, law enforcement cleared the encampment he had relocated to, forcing him to move again. Feeling despondent, he said he had given up on the promise of housing. “Please make this pain stop. I don’t know how much more I can take,” he said.

Buckles was able to grab a few possessions from his RV after it was confiscated, but replacing the documents he needs for housing may take months and repeat visits by outreach workers, said Greg Stupplebeen, an outreach manager with Hope Cooperative.

Even if Buckles had his paperwork in order, “there’s nowhere to put anybody right now,” Stupplebeen told him.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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Mary Delgado’s first pregnancy went according to plan, but when she tried to get pregnant again seven years later, nothing happened. After 10 months, Delgado, now 34, and her partner, Joaquin Rodriguez, went to see an OB-GYN. Tests showed she had endometriosis, which was interfering with conception. Delgado’s only option, the doctor said, was in vitro fertilization.

“When she told me that, she broke me inside,” Delgado said, “because I knew it was so expensive.”

Delgado, who lives in New York City, is enrolled in Medicaid, the federal-state health program for low-income and disabled people. The roughly $20,000 price tag for a round of IVF would be a financial stretch for lots of people, but for someone on Medicaid — for which the maximum annual income for a two-person household in New York is just over $26,000 — the treatment can be unattainable.

Expansions of work-based insurance plans to cover fertility treatments, including free egg freezing and unlimited IVF cycles, are often touted by large companies as a boon for their employees. But people with lower incomes, often minorities, are more likely to be covered by Medicaid or skimpier commercial plans with no such coverage. That raises the question of whether medical assistance to create a family is only for the well-to-do or people with generous benefit packages.

“In American health care, they don’t want the poor people to reproduce,” Delgado said. She was caring full-time for their son, who was born with a rare genetic disorder that required several surgeries before he was 5. Her partner, who works for a company that maintains the city’s yellow cabs, has an individual plan through the state insurance marketplace, but it does not include fertility coverage.

Some medical experts whose patients have faced these issues say they can understand why people in Delgado’s situation think the system is stacked against them.

“It feels a little like that,” said Elizabeth Ginsburg, a professor of obstetrics and gynecology at Harvard Medical School who is president-elect of the American Society for Reproductive Medicine, a research and advocacy group.

Whether or not it’s intended, many say the inequity reflects poorly on the U.S.

“This is really sort of standing out as a sore thumb in a nation that would like to claim that it cares for the less fortunate and it seeks to do anything it can for them,” said Eli Adashi, a professor of medical science at Brown University and former president of the Society for Reproductive Endocrinologists.

Yet efforts to add coverage for fertility care to Medicaid face a lot of pushback, Ginsburg said.

Over the years, Barbara Collura, president and CEO of the advocacy group Resolve: The National Infertility Association, has heard many explanations for why it doesn’t make sense to cover fertility treatment for Medicaid recipients. Legislators have asked, “If they can’t pay for fertility treatment, do they have any idea how much it costs to raise a child?” she said.

“So right there, as a country we’re making judgments about who gets to have children,” Collura said.

The legacy of the eugenics movement of the early 20th century, when states passed laws that permitted poor, nonwhite, and disabled people to be sterilized against their will, lingers as well.

“As a reproductive justice person, I believe it’s a human right to have a child, and it’s a larger ethical issue to provide support,” said Regina Davis Moss, president and CEO of In Our Own Voice: National Black Women’s Reproductive Justice Agenda, an advocacy group.

But such coverage decisions — especially when the health care safety net is involved — sometimes require difficult choices, because resources are limited.

Even if state Medicaid programs wanted to cover fertility treatment, for instance, they would have to weigh the benefit against investing in other types of care, including maternity care, said Kate McEvoy, executive director of the National Association of Medicaid Directors. “There is a recognition about the primacy and urgency of maternity care,” she said.

Medicaid pays for about 40% of births in the United States. And since 2022, 46 states and the District of Columbia have elected to extend Medicaid postpartum coverage to 12 months, up from 60 days.

Fertility problems are relatively common, affecting roughly 10% of women and men of childbearing age, according to the National Institute of Child Health and Human Development.

Traditionally, a couple is considered infertile if they’ve been trying to get pregnant unsuccessfully for 12 months. Last year, the ASRM broadened the definition of infertility to incorporate would-be parents beyond heterosexual couples, including people who can’t get pregnant for medical, sexual, or other reasons, as well as those who need medical interventions such as donor eggs or sperm to get pregnant.

The World Health Organization defined infertility as a disease of the reproductive system characterized by failing to get pregnant after a year of unprotected intercourse. It terms the high cost of fertility treatment a major equity issue and has called for better policies and public financing to improve access.

No matter how the condition is defined, private health plans often decline to cover fertility treatments because they don’t consider them “medically necessary.” Twenty states and Washington, D.C., have laws requiring health plans to provide some fertility coverage, but those laws vary greatly and apply only to companies whose plans are regulated by the state.

In recent years, many companies have begun offering fertility treatment in a bid to recruit and retain top-notch talent. In 2023, 45% of companies with 500 or more workers covered IVF and/or drug therapy, according to the benefits consultant Mercer.

But that doesn’t help people on Medicaid. Only two states’ Medicaid programs provide any fertility treatment: New York covers some oral ovulation-enhancing medications, and Illinois covers costs for fertility preservation, to freeze the eggs or sperm of people who need medical treatment that will likely make them infertile, such as for cancer. Several other states also are considering adding fertility preservation services.

In Delgado’s case, Medicaid covered the tests to diagnose her endometriosis, but nothing more. She was searching the internet for fertility treatment options when she came upon a clinic group called CNY Fertility that seemed significantly less expensive than other clinics, and also offered in-house financing. Based in Syracuse, New York, the company has a handful of clinics in upstate New York cities and four other U.S. locations.

Though Delgado and her partner had to travel more than 300 miles round trip to Albany for the procedures, the savings made it worthwhile. They were able do an entire IVF cycle, including medications, egg retrieval, genetic testing, and transferring the egg to her uterus, for $14,000. To pay for it, they took $7,000 of the cash they’d been saving to buy a home and financed the other half through the fertility clinic.

She got pregnant on the first try, and their daughter, Emiliana, is now almost a year old.

Delgado doesn’t resent people with more resources or better insurance coverage, but she wishes the system were more equitable.

“I have a medical problem,” she said. “It’s not like I did IVF because I wanted to choose the gender.”

One reason CNY is less expensive than other clinics is simply that the privately owned company chooses to charge less, said William Kiltz, its vice president of marketing and business development. Since the company’s beginning in 1997, it has become a large practice with a large volume of IVF cycles, which helps keep prices low.

At this point, more than half its clients come from out of state, and many earn significantly less than a typical patient at another clinic. Twenty percent earn less than $50,000, and “we treat a good number who are on Medicaid,” Kiltz said.

Now that their son, Joaquin, is settled in a good school, Delgado has started working for an agency that provides home health services. After putting in 30 hours a week for 90 days, she’ll be eligible for health insurance.

One of the benefits: fertility coverage.

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TREASURE ISLAND, Fla. — Andrew McClave Jr. loved to lift weights. The 6-foot-4-inch bartender resembled a bodybuilder and once posed for a photo flexing his muscles with former pro wrestler Hulk Hogan.

“He was extremely dedicated to it,” said his father, Andrew McClave Sr., “to the point where it was almost like he missed his medication if he didn’t go.”

But the hobby took its toll. According to a police report, a friend told the Treasure Island Police Department that McClave, 36, suffered from back problems and took unprescribed pills to reduce the pain.

In late 2022, the friend discovered McClave in bed. He had no pulse. A medical examiner determined he had a fatal amount of fentanyl, cocaine, and xylazine, a veterinary tranquilizer used to sedate horses, in his system, an autopsy report said. Heart disease was listed as a contributing factor.

McClave is among more than 260 people across Florida who died in one year from accidental overdoses involving xylazine, according to a Tampa Bay Times analysis of medical examiner data from 2022, the first year state officials began tracking the substance. Numbers for 2023 haven’t been published.

The death toll reflects xylazine’s spread into the nation’s illicit drug supply. Federal regulators approved the tranquilizer for animals in the early 1970s and it’s used to sedate horses for procedures like oral exams and colic treatment, said Todd Holbrook, an equine medicine specialist at the University of Florida. Reports of people using xylazine emerged in Philadelphia, then the drug spread south and west.

What’s not clear is exactly what role the sedative plays in overdose deaths, because the Florida data shows no one fatally overdosed on xylazine alone. The painkiller fentanyl was partly to blame in all but two cases in which the veterinary drug was included as a cause of death, according to the Times analysis. Cocaine or alcohol played roles in the cases in which fentanyl was not involved.

Fentanyl is generally the “800-pound gorilla,” according to Lewis Nelson, chair of the emergency medicine department at Rutgers New Jersey Medical School, and xylazine may increase the risk of overdose, though not substantially.

But xylazine appears to complicate the response to opioid overdoses when they do happen and makes it harder to save people. Xylazine can slow breathing to dangerous levels, according to federal health officials, and it doesn’t respond to the overdose reversal drug naloxone, often known by the brand name Narcan. Part of the problem is that many people may not know they are taking the horse tranquilizer when they use other drugs, so they aren’t aware of the additional risks.

Lawmakers in Tallahassee made xylazine a Schedule 1 drug like heroin or ecstasy in 2016, and several other states including Pennsylvania, Ohio, and West Virginia have taken action to classify it as a scheduled substance, too. But it’s not prohibited at the federal level. Legislation pending in Congress would criminalize illicit xylazine use nationwide.

The White House in April designated the combination of fentanyl and xylazine, often called “tranq dope,” as an emerging drug threat. A study of 20 states and Washington, D.C., found that overdose deaths attributed to both illicit fentanyl and xylazine exploded from January 2019 to June 2022, jumping from 12 a month to 188.

“We really need to continue to be proactive,” said Amanda Bonham-Lovett, program director of a syringe exchange in St. Petersburg, “and not wait until this is a bigger issue.”

‘A Good Business Model’

There are few definitive answers about why xylazine use has spread — and its impact on people who consume it.

The U.S. Drug Enforcement Administration in September said the tranquilizer is entering the country in several ways, including from China and in fentanyl brought across the southwestern border. The Florida attorney general’s office is prosecuting an Orange County drug trafficking case that involves xylazine from a New Jersey supplier.

Bonham-Lovett, who runs IDEA Exchange Pinellas, the county’s anonymous needle exchange, said some local residents who use drugs are not seeking out xylazine — and don’t know they’re consuming it.

One theory is that dealers are mixing xylazine into fentanyl because it’s cheap and also affects the brain, Nelson said.

“It’s conceivable that if you add a psychoactive agent to the fentanyl, you can put less fentanyl in and still get the same kick,” he said. “It’s a good business model.”

In Florida, men accounted for three-quarters of fatal overdoses involving xylazine, according to the Times analysis. Almost 80% of those who died were white. The median age was 42.

Counties on Florida’s eastern coast saw the highest death tolls. Duval County topped the list with 46 overdoses. Tampa Bay recorded 19 fatalities.

Cocaine was also a cause in more than 80 cases, including McClave’s, the Times found. The DEA in 2018 warned of cocaine laced with fentanyl in Florida.

In McClave’s case, Treasure Island police found what appeared to be marijuana and a small plastic bag with white residue in his room, according to a police report. His family still questions how he took the powerful drugs and is grappling with his death.

He was an avid fisherman, catching snook and grouper in the Gulf of Mexico, said his sister, Ashley McClave. He dreamed of being a charter boat captain.

“I feel like I’ve lost everything,” his sister said. “My son won’t be able to learn how to fish from his uncle.”

Mysterious Wounds

Another vexing challenge for health officials is the link between chronic xylazine use and open wounds.

The wounds are showing up across Tampa Bay, needle exchange leaders said. The telltale sign is blackened, crusty tissue, Bonham-Lovett said. Though the injuries may start small — the size of a dime — they can grow and “take over someone’s whole limb,” she said.

Even those who snort fentanyl, instead of injecting it, can develop them. The phenomenon is unexplained, Nelson said, and is not seen in animals.

IDEA Exchange Pinellas has recorded at least 10 cases since opening last February, Bonham-Lovett said, and has a successful treatment plan. Staffers wash the wounds with soap and water, then dress them.

One person required hospitalization partly due to xylazine’s effects, Bonham-Lovett said. A 31-year-old St. Petersburg woman, who asked not to be named due to concerns over her safety and the stigma of drug use, said she was admitted to St. Anthony’s Hospital in 2023. The woman, who said she uses fentanyl daily, had a years-long staph infection resistant to some antibiotics, and a wound recently spread across half her thigh.

The woman hadn’t heard of xylazine until IDEA Exchange Pinellas told her about the drug. She’s thankful she found out in time to get care.

“I probably would have lost my leg,” she said.

This article was produced in partnership with the Tampa Bay Times.

En un breve memorando, Joseph Ladapo, Cirujano General de Florida, ha revertido una norma de salud pública que durante mucho tiempo ha mantenido bajo control los brotes de sarampión en el estado.

El 20 de febrero, mientras el sarampión se propagaba en la Escuela Primaria Manatee Bay, en el sur de Florida, Ladapo envió a los padres una carta diciendo que está bien enviar a los niños no vacunados a la escuela en medio del brote.

El Departamento de Salud “está dejando a los padres o tutores tomar decisiones sobre la asistencia a clases”, escribió Ladapo, quien fue nombrado para dirigir la agencia por Ron DeSantis, el gobernador republicano de Florida, cuyo nombre aparece sobre el de Ladapo en el membrete de la carta.

La medida de Ladapo contradice el consejo de los Centros para el Control y Prevención de Enfermedades (CDC).

“Esto no es un problema de los derechos de los padres”, dijo Scott Rivkees, ex cirujano general de Florida, quien ahora es profesor en la Universidad Brown. “Se trata de proteger a los compañeros de clase, maestros y miembros de la comunidad contra el sarampión, que es una enfermedad muy grave y muy contagiosa”, agregó.

La mayoría de las personas que no están protegidas por una vacuna contraerán sarampión si se exponen al virus. Este grupo vulnerable incluye a niños cuyos padres no los vacunan, bebés demasiado pequeños para la recibir la dosis, aquellos que no pueden ser vacunados por razones médicas, y otros que no desarrollan una respuesta inmune fuerte y duradera.

Rivkees estima que alrededor de una décima parte de las personas en una comunidad caen bajo la categoría “vulnerable”.

Los CDC recomiendan que los alumnos no vacunados se queden en casa durante tres semanas después de la exposición. Debido a que el altamente contagioso virus del sarampión se propaga a través de diminutas gotas en el aire y en superficies, se considera que los estudiantes han estado expuestos simplemente por estar en la misma cafetería o aula que alguien infectado.

Y una persona con sarampión puede transmitir la infección antes de desarrollar fiebre, tos, erupción cutánea u otros signos de la enfermedad. Alrededor de 1 de cada 5 personas con sarampión terminan hospitalizadas, 1 de cada 10 desarrolla infecciones de oído que pueden provocar pérdida permanente de la audición, y alrededor de 1 en 1,000 muere por complicaciones respiratorias y neurológicas.

“No sé por qué el Departamento de Salud no seguiría las recomendaciones de los CDC”, dijo Thresia Gambon, presidenta del capítulo de Florida de la Academia Americana de Pediatría y pediatra que ejerce en Miami y Broward, el condado afectado por el actual brote de sarampión. “El sarampión es tan contagioso. Es muy preocupante”, expresó.

Teniendo en cuenta los peligros de la enfermedad, la vacuna es increíblemente segura. En Estados Unidos, una persona tiene cerca de cuatro veces más probabilidades de morir partida por un rayo a lo largo de su vida que de tener una reacción alérgica potencialmente mortal a la vacuna contra el sarampión, las paperas y la rubéola.

Sin embargo, el año pasado un número récord de padres solicitó exenciones de los requisitos de vacunación escolar por motivos religiosos o filosóficos en todo el país.

Los CDC informaron que las tasas de vacunación infantil fueron las más bajas de los últimos 10 años. Además de Florida, este año se han reportado casos de sarampión en otros 11 estados, incluidos Arizona, Georgia, Minnesota y Virginia.

Solo alrededor de un cuarto de los condados de Florida habían alcanzado el umbral del 95% de inmunización en el que las comunidades se consideran bien protegidas contra los brotes de sarampión, según los datos más recientes publicados por el Departamento de Salud estatal en 2022.

En el condado de Broward, donde se han reportado seis casos de sarampión en la última semana, aproximadamente el 92% de los niños en kindergarten habían recibido vacunas rutinarias contra el sarampión, la varicela, la polio y otras enfermedades. El 8% restante incluía a más de 1,500 niños que tenían exenciones de vacunas, indican datos de 2022.

Desde que comenzó el brote, el Departamento de Salud de Broward ha estado ofreciendo vacunas contra el sarampión en la escuela Manatee Bay, según el superintendente escolar.

Si una persona no vacunada recibe una dosis dentro de los tres días posteriores a la exposición al virus, es mucho menos probable que contraiga el sarampión y que lo transmita a otros. Por esta razón, los funcionarios gubernamentales ocasionalmente han ordenado vacunas en emergencias en el pasado.

Por ejemplo, en 1991, el comisionado adjunto de salud de Filadelfia ordenó que los niños fueran vacunados en contra de los deseos de sus padres durante brotes relacionados con sus iglesias. Y durante un gran brote de sarampión en las comunidades judías ortodoxas en Brooklyn en 2019, el comisionado de salud de la ciudad de Nueva York ordenó que cualquier persona que viviera, trabajara o fuera a la escuela en los vecindarios más afectados recibiera la vacuna, a riesgo de enfrentar una multa de $1,000.

En esa ordenanza, el comisionado escribió que la presencia en esas áreas de cualquier persona no vacunada, a menos que tuviera una contraindicación médica, “creaba un riesgo innecesario y evitable de continuar con el brote”.

Con su carta, Ladapo eligió la dirección opuesta, dejando a los padres a cargo debido a la “alta tasa de inmunidad en la comunidad” (datos indican lo contrario), y por la “carga para las familias y el costo educativo de los niños sanos que faltan a la escuela”.

Sin embargo, la carga de un brote aumenta a medida que se propagan los casos de sarampión: se requiere más atención de emergencia, más pruebas y cuarentenas más amplias; y hay más hospitalizaciones.

En 2018, controlar un brote en el sur de Washington con 72 casos costó alrededor de $2.3 millones, además de $76,000 en costos médicos, y una pérdida económica estimada de $1 millón debido a enfermedades, cuarentenas y atención.

Si los números se disparan, la muerte también se convierte en una carga.

Un brote entre una población en gran parte no vacunada en Samoa causó más de 5,700 casos y 83 muertes, principalmente entre niños.

La carta de Ladapo a los padres también marca un cambio en la norma porque los departamentos de salud locales tienden a liderar la contención de brotes de sarampión, no las autoridades estatales o federales. En respuesta a consultas de KFF Health News, el departamento de salud del condado de Broward remitió al departamento de salud del estado de Florida, que Ladapo supervisa.

“El condado no tiene el poder de estar en desacuerdo con el departamento de salud estatal”, dijo Rebekah Jones, científica de datos que fue removida de su cargo en el departamento de salud de Florida en 2020, debido a una discrepancia sobre los datos de coronavirus.

DeSantis nombró a Ladapo como jefe del departamento de salud del estado a fines de 2021, mientras comenzaba a incluir el escepticismo sobre las vacunas contra covid en su plataforma política. En los meses siguientes, el departamento eliminó la información sobre las vacunas contra covid de su página de inicio y sancionó al director de salud de un condado por alentar a su personal a vacunarse, lo que llevó a su renuncia.

En enero, el sitio web del departamento de salud publicó el llamado de Ladapo a frenar la vacunación con vacunas de ARN mensajero contra covid por completo, basado en nociones que los científicos consideran absurdas.

Jones no se sorprendió de ver a Ladapo cambiar de dirección sobre el sarampión. “Creo que esto es el resultado previsible de convertir la retórica antivacunas en un rasgo definitorio del gobierno de Florida”, dijo.

Aunque su última decisión va en contra del consejo de los CDC, la agencia federal rara vez interviene en brotes de sarampión, confiando en que los estados harán bien la tarea.

En un correo electrónico a KFF Health News, el departamento de salud de Florida dijo que estaba trabajando para identificar los contactos de las personas con sarampión, pero que los detalles sobre los casos y lugares de exposición eran confidenciales. Repitió la decisión de Ladapo, agregando: “La recomendación del cirujano general puede cambiar a medida que continúen las investigaciones epidemiológicas”.

Para Gambon, el brote ya es desconcertante. “Me gustaría ver al cirujano general promover lo que es más seguro para los niños y el personal escolar”, dijo, “ya que estoy segura de que hay muchos que pueden no tener una inmunidad tan fuerte como quisiéramos”.