Nada Hassanein, Stateline

Across the nation, Medicaid is the single largest payer for mental health care, and in rural America, residents disproportionately rely on the public insurance program.

But Medicaid cuts in the massive tax and spending bill signed into law earlier this month will worsen mental health disparities in those communities, experts say, as patients lose coverage and rural health centers are unable to remain open amid a loss of funds.

“The context to begin with is, even with no Medicaid cuts, the access to mental health services in rural communities is spotty at best, just very spotty at best — and in many communities, there’s literally no care,” said Ron Manderscheid, former executive director of the National Association of County Behavioral Health and Developmental Disability Directors.

Cuts over the next 10 years could force low-income rural families to pay for mental health care out of pocket on top of driving farther for care, experts say. Many will simply forgo care for depression, bipolar disorder and other illnesses that need consistent treatment.

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“Not only do you have very few services available, but you don’t have the resources to pay for the services,” Manderscheid said. “That makes the problem even worse.”

Rural communities are already at higher risk of suicide, with rates almost doubling over the past two decades. Already, rural communities are grappling with a shortage in mental health professionals, making them more vulnerable to losses compared with more urban areas, experts say.

Paul Mackie, assistant director of the Center for Rural Behavioral Health at Minnesota State University, Mankato, studies rural mental health workforce shortages.

“If it [coverage] goes away, what would then be the person’s next option if they already don’t have the resources?” said Mackie, who grew up on a rural Michigan dairy farm. “You can have a rural psychologist or a rural clinical social worker working under a shingle, literally alone.”

Small rural hospitals often provide critical behavioral health care access, he said. One analysis found the cuts next year would leave 380 rural hospitals at risk of shutting down.

States such as Mackie’s Minnesota, which expanded Medicaid eligibility under the 2010 Affordable Care Act, would suffer significant slashes in federal matches as a result of President Donald Trump’s signature legislation. The law, which includes tax cuts that disproportionately benefit the wealthy, cuts the federal government’s 90% matching rate for enrollees covered under expansion to anywhere from 50% to 74%.

States will have to redetermine eligibility twice a year on millions enrolled under Medicaid expansion. Some Medicaid recipients also will have to prove work history. The new law creates work requirement exceptions for those with severe medical conditions — including mental disorders and substance use — but experts say proving those conditions may be convoluted. The exact qualifications and diagnoses for the exceptions haven’t been spelled out, according to a report by KFF, a health policy research organization.

“You can’t work when your mental illness is not treated,” said Dr. Heidi Alvey, an emergency and critical care medicine physician in Indiana. “It’s so counter to the reality of the situation.”

Alvey worked for seven years at Baylor Scott & White Health’s hospital in Temple, Texas. As nearby rural critical access hospitals and other mental health centers shut down, the hospital became the only access point for people hours away, she said.

“People who just had absolutely no access to care were coming hours in to see us,” she said. Many had serious, untreated mental health conditions, she said, and had to wait days or weeks in the emergency department until a care facility had an open bed.

She’s concerned that Medicaid cuts will only make those problems worse.

Jamie Freeny, director of the Center for School Behavioral Health at advocacy group Mental Health America of Greater Houston, worries for the rural families her center serves. The organization works with school districts across the state, including those in rural communities. Nearly 40% of the state’s more than 1,200 school districts are classified as rural.

She remembers one child whose family had to drive to another county for behavioral health. The family lost coverage during the Medicaid unwinding, as pandemic provisions for automatic re-reenrollment expired. The child stopped taking mental health medication and ended up dropping out of school.

“The child wasn’t getting the medicine that they needed, because their family couldn’t afford it,” Freeny said. “The catalyst for that was a lack of Medicaid. That’s just one family.

“Now, you’re multiplying that.”

Family medicine physician Dr. Ian Bennett sees Medicaid patients at the Vallejo Family Health Services Center of Solano County in California’s Bay Area. The community health clinic serves patients from across the area’s rural farm communities and combines primary care with mental health care services, Bennett said.

“When our patients lose Medicaid, which we expect that they will, then we’ll have to continue to take them, and that will be quite a strain on the finances of that system,” Bennett said. The center could even close, he said.

“The folks who are having the most difficulty managing their lives — and that’s made worse by having depression or substance use disorder — are going to be the folks most likely to drop off,” said Bennett, a University of Washington mental health services researcher. “The impacts down the road are clearly going to be much worse for society as we have less people able to function.”

The psychiatric care landscape across Michigan’s rural western lower peninsula is already scarce, said Joseph “Chip” Johnston. He’s the executive director of the Centra Wellness Network, a publicly funded community mental health care provider for Manistee and Benzie counties. The network serves Medicaid and uninsured patients from high-poverty communities.

“I used to have psychiatric units close by as an adjunct to my service,” he said. “And they’ve all closed. So, now the closest [psychiatric bed] for a child, for example, is at least two hours away.”

Those facilities are also expensive. A one-night stay in an inpatient psychiatric facility can be anywhere from $1,000 to $1,500 a night, he said.

Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org.

Iowa Capital Dispatch is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Iowa Capital Dispatch maintains editorial independence. Contact Editor Kathie Obradovich for questions: info@iowacapitaldispatch.com.

Mosquito-borne illnesses are a growing concern in Northeastern states, with health officials monitoring cases and advising residents to avoid outdoor activities near standing water and other environments prone to mosquito spread.

Of particular concern is eastern equine encephalitis, a rare disease that can lead to serious and fatal illness, caused by mosquitoes carrying the virus.

Known as EEE or “triple E,” the virus can cause disease in humans and animals such as horses and birds. It doesn’t spread from human to human, but is transmitted through the bite of an infected mosquito.

While most people don’t develop symptoms or serious illness, 1 in 3 people who become seriously ill from the virus die, and about half of those who recover from severe cases will still experience long-term physical and cognitive effects, according to the federal Centers for Disease Control and Prevention. Symptoms can include fever, headache, vomiting and drowsiness. Encephalitis is a rare and serious complication in which the infection causes inflammation in the brain.

Eight states — Massachusetts, New Hampshire, New Jersey, New York, North Carolina, Rhode Island, Vermont and Wisconsin — have reported human cases of the virus this year, for a total of 16 cases, according to the latest CDC data. Other states have seen cases in animals only. In Maine this year, triple E was found in two emus and one wild bird.

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In August, Massachusetts officials said they would begin spraying for mosquitoes in two counties after a man in his 80s contracted the virus, four years after the state last saw an outbreak that led to 17 confirmed cases and seven deaths.

Also in August, New Hampshire confirmed its first EEE death this year; it was the first infection the state had seen in a decade, according to state health officials. So far this year, the state has confirmed five total cases in humans, and the disease has been detected in one horse and seven mosquito batches. The state last saw infections in 2014, when three people were infected and two of them died.

Preventive steps

In recent weeks, New York confirmed its first case and death since 2015. The death in Ulster County, about 100 miles north of New York City, prompted Democratic Gov. Kathy Hochul to issue a declaration of imminent threat to public health, and to provide state resources to local health agencies to take preventive action, including mosquito spraying.

The state also is making insect repellent available at state parks and campgrounds; posting signs to raise awareness of EEE; consulting with local health officials about limiting park hours and camping availability during dawn and dusk, the hours of peak mosquito activity; and using social media to educate New Yorkers on how to avoid mosquito bites.

State officials said the person who died in Ulster County was an older adult, but wouldn’t share details as they investigate factors around the case.

Bryon Backenson, epidemiologist and director of the New York State Department of Health’s Bureau of Communicable Disease Control, said about a dozen counties throughout the state take part in mosquito surveillance, but rural Ulster County wasn’t one of them.

While the virus doesn’t spread from horses to humans, researchers keep track of EEE cases in horses to determine how prevalent the virus is in a particular area.

This year, there were 20 cases of EEE reported in horses across about a dozen New York counties. The state has never had so many cases, nor in so many counties, in a single year, Backenson said.

“Horses, in many ways, can act as sentinels for us,” Backenson said. “We can oftentimes use horses as an indication that triple E may be in a particular area at a particular time. If a horse tests positive, we know that there are mammal-biting mosquitoes that are out there and active.”

Ulster County did have a horse case that preceded the human case, but that horse wasn’t in close proximity to where the individual lived, Backenson noted.

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Philip Armstrong, chief scientist at the Center for Vector Biology & Zoonotic Diseases at the Connecticut Agricultural Experiment Station, said while his state hasn’t seen cases, the regional clusters are cause for vigilance.

“This is definitely one of the more active years,” he said. “I would say, about every four or five years, we see these sort of regional outbreaks that occur.”

Armstrong said his team is still collecting and testing mosquitoes.

“So far, we are lucky in Connecticut in that we have not had a human case,” he said. “But sometimes these things come out of the woodwork later in the season — you just don’t know. I’m not ready to declare victory yet.”

Climate change’s impact

There is no human vaccine or medicine for triple E. Experts say residents can protect themselves by using insect repellent and wearing long sleeves and pants when going outside; avoiding the outdoors at dusk and dawn when mosquitoes are most active or taking extra precautions when outside at those times; and draining sources of standing water, such as bird baths and wheelbarrows, a prime environment for mosquito egg-laying.

Dr. Erin Staples, a physician and medical epidemiologist with the CDC’s Division of Vector-Borne Diseases in Fort Collins, Colorado, told Stateline the U.S. typically sees an average of seven cases annually. In 2019, the nation saw 38 cases — the highest number of cases ever reported in a year.

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Climate change can increase risk of vector-borne diseases, including those from mosquitoes, as increased rainfall and warmer temperatures create favorable conditions that can boost their populations.

While it’s not unusual to see sporadic infections of triple E or West Nile virus from year to year, Staples said, changes in bird and mosquito populations and weather patterns can affect the number of cases.

“Climate is one of many factors that can impact vector-borne diseases. Changes in climate lead to changes in the environment, which can change where and how often vector-borne diseases, like EEE and West Nile, occur,” Staples wrote in an email, noting that flooding can also change where cases are seen.

Sen Pei, an assistant professor of environmental health sciences at Columbia University’s Mailman School of Public Health, said along with rising temperatures that can cause expansion of mosquito habitats, climate change-related disasters such as hurricanes can alter how and where people live. Officials should monitor for vector-borne diseases after disasters.

“It’s a systematic impact. Vector-borne disease is such a complicated ecosystem,” he said.

Stateline is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Stateline maintains editorial independence. Contact Editor Scott S. Greenberger for questions: info@stateline.org. Follow Stateline on Facebook and X.

In the months after the U.S. Supreme Court struck down the constitutional right to an abortion, there was a spike in the number of women seeking sterilizations to prevent pregnancy, a recent study shows.

Researchers saw a 3% increase in tubal sterilizations per month between July and December 2022 in states with abortion bans, according to the study published in September in JAMA, a journal from the American Medical Association. The Supreme Court struck down Roe v. Wade in June 2022.

The study looked at the commercial health insurance claim records of 1.4 million people from 15 states with abortion bans (Alabama, Arizona, Arkansas, Idaho, Indiana, Kentucky, Mississippi, Missouri, Oklahoma, Tennessee, Texas, Utah, West Virginia, Wisconsin and Wyoming). The study also examined the records of about 1.5 million people living in states with some abortion restrictions and 1.8 million in states where abortion remains legal. The researchers excluded 14 states that didn’t have records available for 2022.

“It’s probably an indication of women [who] wanted to reduce uncertainty and protect themselves,” said lead author Xiao Xu, an associate professor of reproductive sciences at Columbia University. In the first month after the ruling, sterilizations saw a one-time increase across all states included in the study, Xu and her team found. Her team also found continued increases in states that limited abortion to a certain gestational age, but those were not statistically significant.

The researchers compared records for three groups: States with a total or near-total ban on abortion, including states where bans were temporarily blocked; states where laws explicitly recognized abortion rights; and limited states, where abortion was legal up to a certain gestational age.

While the study captures only the early months following the Dobbs ruling that overturned Roe v. Wade, experts say it’s part of an increasing body of evidence that shows a growing urgency for sterilization procedures amid more limited access to abortions, reproductive health care and contraception. Other studies have shown increases in tubal sterilization (commonly known as “getting your tubes tied”) and vasectomy requests and procedures post-Dobbs.

Diana Greene Foster, a professor and research director in reproductive health at the University of California, San Francisco, said the results are not surprising, given the negative repercussions for women who seek to end their pregnancies but are not allowed to do so.

Foster led the landmark Turnaway Study, which for a decade followed women who received abortions and those who were denied abortions. It found that women forced to carry a pregnancy to term experienced financial hardship, health and delivery complications, and were more likely to raise the child alone.

“We have found that women are able to foresee the consequences of carrying an unwanted pregnancy to term,” Foster told Stateline. “The reasons people give for choosing an abortion — insufficient resources, poor relationships, the need to care for existing children — are the same negative outcomes we see when they cannot get an abortion.

“So it is not surprising that some people will respond to the lack of legal abortion by trying to avoid a pregnancy altogether.”

Few doctors and services

States with abortion bans and other restrictions also tend to have large swaths of maternal health care “deserts,” where there are too few OB-GYNs and labor and delivery facilities. That creates greater maternal health risks.

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One such state is Georgia, where until a court ruling this week, abortion was banned after six weeks. Dr. LeThenia “Joy” Baker, an OB-GYN in rural Georgia, said she sees patients in their early 20s who have multiple children and are seeking sterilizations to prevent further pregnancies, or who have conditions that make pregnancy dangerous for them. Her state has one of the highest maternal death rates in the nation.

On Monday, a Georgia county judge struck down the state’s six-week abortion ban, meaning that for now, women have access to the procedure up to about 22 weeks of pregnancy. The state is appealing the decision, and it’s expected to eventually be decided by the state Supreme Court.

The county judge’s ruling comes two weeks after ProPublica reported that two women in the state died after they couldn’t access legal in-state abortions and timely medical care for rare complications from abortion pills.

Black and Indigenous women disproportionately experience higher rates of complications, such as preeclampsia and hemorrhage, which contributes to their higher maternal mortality and morbidity rates. Baker said some of her patients say they want to avoid risking another pregnancy because of those previous complications.

“I have had quite a few patients, who were both pregnant and not pregnant, who inquire about sterilization,” she said. “I do think that patients are thinking a lot more about their reproductive life plan now, because there is very little margin.”

Along with the state’s abortion restrictions, Baker said women in her Bible Belt community feel social pressure that can push them toward sterilization.

“It is definitely more socially acceptable to say, ‘I’m going to get my tubes tied or removed,’ than to say, ‘Hey, I want to find abortion care,’” Baker said.

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In states where lawmakers have proposed restrictions on contraception, women might feel tubal sterilization to be the most surefire way to prevent pregnancy. Megan Kavanaugh, a contraception researcher at the Guttmacher Institute, a reproductive health policy research center that supports abortion rights, said the research doesn’t say whether women who seek sterilization would have preferred another form of contraception.

“We need to both understand which methods people are using and whether those methods are actually the methods they want to be using,” said Kavanaugh, whose team studied contraceptive access and use in Arizona, Iowa, New Jersey and Wisconsin. “It’s really important to be monitoring both use and preferences in terms of heading towards an ideal where those are aligned.”

Tubal sterilizations can still fail at preventing a pregnancy, Foster said. One recent study noted that up to 5% of patients who underwent a tubal sterilization got pregnant later.

“If people are choosing sterilization who would otherwise pick something less permanent, then that is another very sad outcome of these abortion bans,” she added.

Another recent study, by Jacqueline Ellison, a University of Pittsburgh assistant professor who researches health policy, found that more young patients — both women and men — sought permanent contraceptive procedures in the wake of the Dobbs decision. The study focused on people ages 18 to 30 — the age group most likely to seek an abortion and the ones who previous studies suggest are most likely to experience “sterilization regret,” Ellison said.

A troubled history

The issue also can’t be disentangled from the nation’s history of coercive sterilizations, Ellison and other experts said. In the 1960s and 1970s, federally funded nonconsensual sterilization procedures were performed on Indigenous, Black and Hispanic women, as well as people with disabilities.

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“People feeling pressured to undergo permanent contraception and people being forced into using permanent contraception are just two sides of the idea of reproductive oppression in this country,” Ellison said. “They’re just manifested in different ways.”

Medicaid, the joint federal-state health insurance program for low-income people, now has regulations designed to prevent coerced procedures. But the rules can have unintended consequences, said Dr. Sonya Borrero, an internal medicine physician and director of the University of Pittsburgh’s Center for Innovative Research on Gender Health Equity.

The process includes a 30-day waiting period after a patient signs a sterilization procedure consent form, Borrero noted. But pregnant women who want the procedure done right after delivery might not reach the 30-day threshold if they go into early labor, she said. She added that some patients are confused by the form.

Borrero launched a tool called MyDecision/MiDecisión, an English and Spanish web-based tool that walks patients through their tubal ligation decision and dispels misinformation around the permanent procedure.

“The importance and the relevance of it right now is particularly pronounced,” she said.

Stateline is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Stateline maintains editorial independence. Contact Editor Scott S. Greenberger for questions: info@stateline.org. Follow Stateline on Facebook and X.