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Emergency contraception marks a new battle line in Texas

COLLEGE STATION, Texas — “Mysterious Dolphin” needed an emergency contraception pill dropped off on a porch outside of town.

Allison Medulan, a sophomore at Texas A&M University who had just come from biology class, saw the request on her cellphone via an anonymous text hotline. She gathered a box of the one-dose contraceptive, a pregnancy test, and a few condoms from her apartment and headed over. Inside a bewildering development of modest townhomes, Medulan tucked the plastic delivery bag next to the doormat.

Closing the car door, she stared ahead and took a breath. Medulan, 20, didn’t know the woman’s real name. It had been converted into a moniker by another volunteer operating the hotline.

“I’ve done what I can,” she said.

In this college town in farm country about two hours north of Houston, Medulan and other volunteers for Jane’s Due Process, an Austin-based nonprofit, are trusted allies for panicked young women scrambling for a solution after contraceptive failure or unprotected sex.

Sexual health advocates have long sought to expand access to emergency contraception — over-the-counter medications that prevent fertilization if taken within days of sexual intercourse — with the aim of preventing unplanned pregnancies that can derail educational and professional goals for women and teenagers. A bill that recently passed the Illinois General Assembly would require public universities to offer emergency contraception in vending machines, and volunteer distribution networks exist in numerous states, including Pennsylvania, Alabama, and Georgia.

But in Texas, these grassroots efforts in College Station, Lubbock, Austin, and the Rio Grande Valley have taken on heightened urgency after state lawmakers banned nearly all abortions after around six weeks of pregnancy. Demand for emergency contraception has skyrocketed. Nurx, an online prescription company, registered a 173% increase in orders from Texas in September 2021, the month the law took effect, compared with the previous month. Every Body Texas, an Austin-based group that awards federal birth control funding, received more than 200 requests for emergency contraception the first week its website began taking orders.

“There is anxiety around these laws and feeling like you’re going to be punished for having sex and pregnancy is that punishment,” said Graci D’Amore, 33, program and operations manager at Jane’s Due Process.

Jane’s Due Process reaches out to teens on Instagram and Facebook with digital ads that clear up fallacies about who can buy emergency contraception and where. Minors in Texas and nearly two dozen other states, including teen mothers already raising a child, must have their parents’ consent to get a prescription for hormonal birth control.

Emergency contraception, which is available without a prescription, is exempted from those restrictions. But the medication can be difficult to find in rural areas of Texas. And many pharmacies that do carry it keep it in locked cases or behind the pharmacy counter, requiring purchasers to ask for access. At a cost of $35 to $50 a pill, the medication is unaffordable for some young people.

The Jane’s Due Process “repro kits,” delivered free to those who request a pill via text message or phone call, include a booklet that lists the nearest abortion clinic, often hours away for Texans outside the state’s metropolitan areas.

“It is a Texas teen’s right to buy emergency contraception, pregnancy tests, and condoms,” said D’Amore. “Not only are we trying to provide access but also education.”

In many ways, these groups operate in an educational desert when it comes to abortion, contraception, and even sex. In Texas, many Planned Parenthood and other sexual health clinics that helped an earlier generation of women are long gone, replaced by hundreds of crisis pregnancy centers that counsel women against abortion and do not offer contraception.

As Texas swerved sharply to the right in recent decades, anti-abortion politicians vowed to run Planned Parenthood out of the state, enacting a cascade of restrictions. In 2011, Republican lawmakers slashed funding for the state family planning program by 66%, and more than 80 family planning clinics closed.

The impact was swift. Researchers found that from 2011 to 2014 the number of women using the most effective forms of birth control — IUDs, implants, and injections — declined by a third in the counties that had been serviced by a Planned Parenthood affiliate, while births by poor women on Medicaid increased 27% in those counties. The state partially restored funding in recent years, but many clinics never reopened.

To fill that gap, enter a network of volunteer groups, nearly all made up of women — young and old. With the politics of abortion and contraception converging, they know they are the next target. Many of the people seeking to ban abortion entirely in Texas also want to ban emergency contraception. They contend that life begins at fertilization and that any medication that interrupts that process violates their religious beliefs.

Religious activists in Texas have been out front in this effort, harnessing the state and local governments in their mission. Texas is the only state that does not pay for any form of emergency contraception for low-income women and girls in its state family planning program. Local councils in at least 40 Texas towns have adopted an ordinance that declares them “sanctuary cities for the unborn.” The movement, which began in Waskom, Texas, along the Louisiana border, criminalizes abortion and bans emergency contraception.

Other states are making similar moves.

In Arizona, Arkansas, Georgia, Idaho, Illinois, Mississippi, and South Dakota, pharmacists can refuse to dispense emergency contraception if it conflicts with their religious beliefs, and Arkansas and North Carolina exclude the medication from mandatory contraceptive coverage, according to the Guttmacher Institute, a research group that supports abortion rights. Alabama lawmakers have introduced legislation that would prohibit the state health department from using state funds to pay for emergency contraception.

Many conservative Catholics and evangelical Protestants contend that the pills — marketed under the brand names Plan B and Ella — and intrauterine devices are forms of abortion. But emergency contraception is entirely different from the medications prescribed to induce abortions.

Plan B is a hormonal medication that prevents pregnancy by delaying the release of an egg from the ovary or preventing fertilization. It does not harm an existing pregnancy. IUDs generally work by preventing sperm from reaching an egg, and some forms make the uterus lining inhospitable to attachment of a fertilized egg.

For Nimisha Srikanth, a public health major at Texas A&M in College Station, pushing back against that conservative tide has become an ethical crusade. “People have sex because they feel good, not because they want a kid,” she said, sitting at the kitchen table in her tidy off-campus apartment. “Taking that away from them is morally incorrect.”

A petite 21-year-old with hip-length black hair, Srikanth keeps boxes of donated Plan B, condoms, and pregnancy tests tucked under her bed. As president of Feminists for Reproductive Equity and Education, known as FREE Aggies, she operates an emergency contraception text hotline and delivers free pills to any A&M student who contacts her, usually meeting them at the student center and handing over a brown paper bag.

Since she began running FREE Aggies, she has rooted out spies from campus anti-abortion groups who crashed online meetings and switched to the private chat platform Discord. “If A&M requests our correspondence, Discord can’t give it to them,” she said.

The emergency contraception deliveries by volunteers with FREE Aggies and Jane’s Due Process are legal, but their clandestine nature fuels the stigma that young people caring for their sexual health is shameful, said Holly Musick, who attended Texas A&M in the late 1970s, a few years after abortion became legal nationwide.

“It was a much more liberal time,” she told Medulan when they met recently at the student center. “There was a Planned Parenthood on the north side of town, and students could walk to get birth control pills.”

Now, Musick, 64, volunteers for the Jane’s Due Process hotline, dropping off pills around town. The precariousness of women’s access to sexual health care scares her. She signed up for a delivery that had been requested during a narrow window of time at a specific place. “It got canceled right before I left my house, and I’m thinking, ‘This poor girl.’”

Medulan brims with anger. She was raised to think she could be anything in life but sees how abortion politics in Texas have circumscribed her world. Her boyfriend often accompanies her to make deliveries. He worries an anti-abortion radical will try to kill her. She’s been asked to leave the pills under a car, under a doormat, in a fake plant outside a house.

“It shouldn’t be shameful,” she said. “It shouldn’t be something you have to hide in a bush and make sure no one sees you grab this unmarked bag.”

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.

Subscribe to KHN's free Morning Briefing.

Montana sending troubled kids to programs that Paris Hilton and other students have accused of abuse

The high demand for treatment for children with behavioral and substance abuse problems has led Montana health officials to spend Medicaid funds to send kids, including those who are foster children and wards of the state, to residential programs in other states with less stringent oversight.

Some of those children have been sent to out-of-state programs that have been accused of abuse and mistreatment, according to documents from state agencies and media reports.

Shipping those kids out of state for treatment for behavioral and substance use disorders comes with a high price tag, and often the children’s issues are not resolved or are even worse, said Michael Chavers, CEO of Yellowstone Boys and Girls Ranch. “When they return to us, they return with worse outcomes and for higher cost,” Chavers told Montana lawmakers last fall.

In 2019, Montana increased its oversight of private alternative treatment programs for young people, abolishing an industry-controlled oversight board and making the programs subject to Montana Department of Public Health and Human Services’ regulations and inspections. By the end of 2020, 11 of the 19 programs operating in Montana had closed.

This month, approximately 90 children from Montana were attending facilities approved by Montana’s Medicaid program in 10 other states, according to state officials. The facilities were in Arkansas, Florida, Georgia, Iowa, Kansas, Mississippi, Oklahoma, Tennessee, Utah, and Wyoming.

By comparison, Medicaid paid for 171 Montana children to be treated at in-state psychiatric residential facilities and 407 kids to live in in-state therapeutic group homes during the state’s previous fiscal year, which ended June 30, according to health department officials.

Nearly all the out-of-state programs that have been approved by Montana’s Medicaid program and are currently housing kids from Montana have faced allegations of abuse or have histories of noncompliance with state regulations, according to state documents, inspection reports, and investigations by news organizations.

Jon Ebelt, a Montana health department spokesperson, confirmed that there have been reports of abuse or neglect of young people from Montana at out-of-state facilities during the past two years, although he did not specify which facilities or how many reports. In some cases, Montana has moved young people from out-of-state programs because of concerns about facilities, he added, without providing details.

The state where an allegation of abuse or neglect of a Montana child occurs is responsible for investigating it, Ebelt said.

Why Out of State?

The majority of children attending out-of-state Medicaid-funded treatment facilities are sent by their parents or guardians, although some are referred by the state health department’s Child and Family Services Division or by the state’s juvenile justice system as wards of the state, Ebelt said.

Kids are sent to programs out of state because of a lack of available beds at in-state facilities stemming from the state’s low rate of reimbursement and staffing shortages, said program administrators of Montana’s psychiatric residential treatment facilities and therapeutic group homes. In-state providers are reimbursed an average of $405 per day per child, while out-of-state providers are reimbursed an average of $615 per day per child.

For the fiscal year that ended June 30, Montana spent a total of $12.6 million for out-of-state psychiatric residential treatment facility stays and $4.7 million for out-of-state therapeutic group home stays, Ebelt said.

“It is always our preference to serve youth with serious emotional disturbances in or near their home communities,” Ebelt said. “However, sometimes, due to a variety of factors, including acuity of symptoms, need for specialized care, or in-state bed availability, youth are referred to out-of-state providers.”

Among the programs eligible for Montana Medicaid and that are currently housing kids from Montana is Provo Canyon School in Utah, where Paris Hilton and hundreds of other students have alleged they were abused, according to lawsuits, former students who have shared accusations about abuse at the program, news organizations’ investigations, and state documents. Those allegations led Utah to increase oversight of residential youth programs.

When reached for comment, Provo Canyon School sent a statement, last updated in August 2021, that says Provo does not “condone or promote any form of abuse” and that the program is “committed to providing high-quality care to youth with special, and often complex, emotional, behavioral and psychiatric needs.”

Montana is also sending kids to another Utah facility, Falcon Ridge Ranch, an employee of which was arrested and charged with multiple counts of sexual battery and distributing harmful material to minors in March 2021, according to the St. George Spectrum & Daily News. The employee pleaded guilty to three misdemeanor counts of sexual battery in a plea agreement with prosecutors in January, said Cade Stubbs, the clerk of court for Utah’s 5th District Court. Falcon Ridge Ranch was owned by Sequel Youth and Family Services at the time, and is now owned by Rite of Passage.

Minnesota, Oregon, and Maryland stopped sending children to Sequel programs after the May 2020 death of a 16-year-old student at a Michigan facility. Cornelius Frederick died after staff members restrained him at Sequel’s now-closed Lakeside Academy, according to an investigation report by Michigan child welfare officials. California and Washington also severed ties with Sequel after an article published by APM Reports in September 2020 detailed abuse and noncompliance with state regulations at Sequel facilities across the country.

An investigation by The Imprint and the San Francisco Chronicle found that of the hundreds of alleged violations or deficiencies at Sequel facilities that child welfare officials in California and other states have investigated, more than 75% resulted in confirmation by state authorities that violations had occurred.

Officials from Sequel did not respond to multiple requests for comment.

Regulatory Confusion

A January report from the federal Government Accountability Office found that monitoring out-of-state youth treatment facilities is difficult because of “state challenges in collecting and reporting facility-level information.” It also found that different definitions of maltreatment, fear of retaliation, and the inability of the residents to communicate with others outside the program posed challenges for reporting maltreatment and data collection.

The report found that federal agencies have been inconsistent in addressing state and federal program noncompliance and recommended improved state oversight and stronger enforcement to hold facilities accountable.

Oregon state Sen. Sara Gelser Blouin, a Democrat from Corvallis, experienced those regulatory problems firsthand when she was investigating reports that Oregon children had been mistreated at Sequel’s Northern Illinois Academy in 2019.

Gelser Blouin said she contacted Oregon’s abuse investigator and the state health department but found no agency officials able to investigate the matter. Gelser Blouin then contacted officials in Illinois she thought might have the authority to investigate Northern Illinois Academy, with the same result.

“Nobody thought they had the authority to investigate,” Gelser Blouin said. “They just kept saying, ‘Well they’re accredited by the Joint Commission.’ So I called the Joint Commission, and the Joint Commission told me that they are not a ‘Betty Crocker seal of approval’ for child safety.”

The Joint Commission is a private organization that accredits health care organizations and programs in the United States and is funded primarily by the fees it charges facilities for accreditation. In some states, accreditation from the Joint Commission can relieve treatment facilities of oversight from most other organizations.

At Gelser Blouin’s request, the federal Centers for Medicare & Medicaid Services initiated an unannounced survey of Northern Illinois Academy. CMS surveyors declared all the kids at Northern Illinois Academy at immediate risk of serious injury or death.

One month earlier, in November 2019, the Joint Commission had reaccredited all Sequel facilities, including Northern Illinois Academy, in a pilot systemwide accreditation.

Northern Illinois Academy closed last year after a state-funded report by a disability-rights organization documented allegations of abuse and neglect, leading the state to remove all the kids in its care.

Oregon and California Lead With Bans

Oregon and California are the only states that have passed legislation to prevent young people from being placed in facilities that are not overseen by a youth’s home state.

California banned the practice of sending foster children charged with crimes to out-of-state programs in July 2021. That same month, Oregon, driven largely by the work of Gelser Blouin, became the first and only state to require any out-of-state facility housing Oregon children to comply with Oregon regulations and be licensed by the Oregon Department of Human Services.

Gelser Blouin is now working with other youth rights advocates, including Paris Hilton, to champion a federal bill called the Accountability for Congregate Care Act. It would establish standard regulations and common definitions for abuse and treatment across the states and identify the rights of children in institutional settings.

The bill would also create a federal database to track placements of young people, critical incident reports, and complaints, among other information. Currently, complaints against programs are funneled through various state agencies and accrediting bodies.

In Montana, for example, Ebelt said complaints about out-of-state programs housing Montana’s young people can be filed in various ways “due to the various people and entities who interact with or have oversight of out-of-state programs.”

The bill would also define different types of programs, which Caroline Lorson, an advocate working on the federal legislation, said is at the heart of the need for change.

“They all have different requirements, they all have different standards, and they all have different agencies that interact with them, and that’s why they’ve been hard to regulate,” Lorson said.

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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Which companies aren’t exiting Russia? Big Pharma

Even as the war in Ukraine has prompted an exodus of international companies — from fast-food chains and oil producers to luxury retailers — from Russia, U.S. and global drug companies said they would continue manufacturing and selling their products there.

Airlines, automakers, banks, and technology giants — at least 320 companies by one count — are among the businesses curtailing operations or making high-profile exits from Russia as its invasion of Ukraine intensifies. McDonald’s, Starbucks, and Coca-Cola announced a pause in sales this week.

But drugmakers, medical device manufacturers, and health care companies, which are exempted from U.S. and European sanctions, said Russians need access to medicines and medical equipment and contend that international humanitarian law requires they keep supply chains open.

“As a health care company, we have an important purpose, which is why at this time we continue to serve people in all countries in which we operate who depend on us for essential products, some life-sustaining,” said Scott Stoffel, divisional vice president for Illinois-based Abbott Laboratories, which manufactures and sells medicines in Russia for oncology, women’s health, pancreatic insufficiency, and liver health.

Johnson & Johnson — which has corporate offices in Moscow, Novosibirsk, St. Petersburg, and Yekaterinburg — said in a statement, “We remain committed to providing essential health products to those in need in Ukraine, Russia, and the region, in compliance with current sanctions and while adapting to the rapidly changing situation on the ground.”

The reluctance of drugmakers to pause operations in Russia is being met with a growing chorus of criticism.

Pharmaceutical companies that say they must continue to manufacture drugs in Russia for humanitarian reasons are “being misguided at best, cynical in the medium case, and outright deplorably misleading and deceptive,” said Jeffrey Sonnenfeld, a professor at the Yale School of Management who is tracking companies that have curtailed operations in Russia. He noted that banks and technology companies also provide essential services.

“Russians are put in a tragic position of unearned suffering. If we continue to make life palatable for them, then we are continuing to support the regime,” Sonnenfeld said. “These drug companies will be seen as complicit with the most vicious operation on the planet. Instead of protecting life, they are going to be seen as destroying life. The goal here is to show that Putin is not in control of all sectors of the economy.”

U.S. pharmaceutical and medical companies have operated in Russia for decades, and many ramped up operations after Russia invaded and annexed Crimea in 2014, navigating the fraught relationship between the U.S. and Russia amid sanctions. In 2010, Vladimir Putin, then Russian prime minister, announced an ambitious national plan for the Russian pharmaceutical industry that would be a pillar in his efforts to reestablish his country as an influential superpower and wean the country off Western pharmaceutical imports. Under the plan, called “Pharma-2020” and “Pharma-2030,” the government required Western pharmaceutical companies eager to sell to Russia’s growing middle class to locate production inside the country.

Pfizer, Johnson & Johnson, Novartis, and Abbott are among the drugmakers that manufacture pharmaceutical drugs at facilities in St. Petersburg and elsewhere in the country and typically sell those drugs as branded generics or under Russian brands.

In addition, pharmaceutical manufacturing plants in Kaluga, a major manufacturing center for Volkswagen and Volvo southwest of Moscow, have been funded through a partnership between Rusnano, a state-owned venture that promotes the development of high-tech enterprises, and U.S. venture capital firms.

Russia also has sought to position itself as an attractive research market, offering an inexpensive and lax regulatory environment for clinical drug trials. Last year, Pfizer conducted in Russia clinical trials of Paxlovid, its experimental antiviral pill to treat covid-19. Before the invasion began in late February, 3,072 trials were underway in Russia and 503 were underway in Ukraine, according to BioWorld, a reporting hub focused on drug development that features data from Cortellis.

AstraZeneca is the top sponsor of clinical trials in Russia, with 49 trials, followed by a subsidiary of Merck, with 48 trials.

So far, drugmakers’ response to the Ukraine invasion has largely centered on public pledges to donate essential medicines and vaccines to Ukrainian patients and refugees. They’ve also made general comments about the need to keep open the supply of medicines flowing within Russia.

Abbott has pledged $2 million to support humanitarian efforts in Ukraine, and Pfizer, based in New York, said it has supplied $1 million in humanitarian grants. Swiss drug maker Novartis said it was expanding humanitarian efforts in Ukraine and working to “ensure the continued supply of our medicines in Ukraine.”

But no major pharmaceutical or medical device maker has announced plans to shutter manufacturing plants or halt sales inside Russia.

In an open letter, hundreds of leaders of mainly smaller biotechnology companies have called on industry members to cease business activities in Russia, including “investment in Russian companies and new investment within the borders of Russia,” and to halt trade and collaboration with Russian companies, except for supplying food and medicines. How many of the signatories have business operations in Russia was unclear.

Ulrich Neumann, director for market access at Janssen, a Johnson & Johnson company, was among those who signed the letter, but whether he was speaking for the company was unclear. In its own statement posted on social media, the company said it’s “committed to providing access to our essential medical products in the countries where we operate, in compliance with current international sanctions.”

GlaxoSmithKline, headquartered in the United Kingdom, said in a statement that it’s stopping all advertising in Russia and will not enter into contracts that “directly support the Russian administration or military.” But the company said that as a “supplier of needed medicines, vaccines and everyday health products, we have a responsibility to do all we can to make them available. For this reason, we will continue to supply our products to the people of Russia, while we can.”

Nell Minow, vice chair of ValueEdge Advisors, an investment consulting firm, noted that drug companies have been treated differently than other industries during previous global conflicts. For example, some corporate ethicists advised against pharmaceutical companies’ total divestment from South Africa’s apartheid regime to ensure essential medicines flowed to the country.

“There is a difference between a hamburger and a pill,” Minow said. Companies should strongly condemn Russia’s actions, she said, but unless the U.S. enters directly into a war with Russia, companies that make essential medicines and health care products should continue to operate. Before U.S. involvement in World War II, she added, there were “some American companies that did business with Germany until the last minute.”

KHN senior correspondent Arthur Allen contributed to this article.

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