If confirmed by the Senate, Jackson will be the first Black woman to serve on the Supreme Court. She would replace Justice Stephen Breyer, who is retiring this summer. CNN first reported that Biden will announce her nomination at the White House. 

Jackson, a top contender from the start, currently serves on the U.S. Court of Appeals for the D.C. Circuit. She was previously on President Barack Obama’s short list for a Supreme Court pick in 2016 after Justice Antonin Scalia died in February of that year.

Jackson, who was born in Washington, D.C., but grew up in Miami, has worked as a public defender and was confirmed by Congress in 2009 to serve as vice chair of the U.S. Sentencing Commission from 2010 to 2014. During her tenure, the commission reduced sentences for many crack cocaine offenses, where research has consistently shown disproportionate sentencing rates between Black and white offenders.

For some counties and cities that share a public health agency with other local governments, differences over mask mandates, business restrictions, and other COVID preventive measures have strained those partnerships. At least two have been pushed past the breaking point.

A county in Colorado and a small city in Southern California are splitting from their longtime public health agencies to set up their own local departments. Both Douglas County, Colorado, and West Covina, California, plan to contract some of their health services to private entities.

In Douglas County, which is just south of Denver and has one of the nation’s highest median household incomes, many residents had opposed mask mandate guidance from the Tri-County Health Department, a partnership among Adams, Arapahoe, and Douglas counties. Tri-County issued a mask order for the counties’ school districts in September 2021 and, within days, conservative Douglas County announced its commissioners had voted unanimously to form its own health department.

Douglas County, which in 1966 joined what was then called the Tri-County District Health Department, is phasing out of the partnership, with plans to exit entirely by the end of this year. It has already taken over many of its own COVID relief efforts from Tri-County.

It is contracting things like COVID case investigation, contact tracing, and isolation and quarantine guidance to a private consultant, Jogan Health Solutions, founded in early 2021. The contract is reportedly worth $1.5 million.

“We believe the greatest challenges are behind us … those associated with being one of three counties with differing and competing public health demands, on a limited budget,” Douglas County spokesperson Wendy Manitta Holmes said in a statement.

Daniel Dietrich, Jogan Health’s president, declined a request for an interview. “All of the data that Jogan Health is collecting is being relayed directly to Douglas County so that public policy aligns with real-time data to keep the residents of Douglas County safe,” Jogan Health spokesperson Sam Shaheen said in a prepared statement.

A similar situation is playing out east of Los Angeles, in West Covina, California. Its City Council has voted to terminate its relationship with the Los Angeles County Department of Public Health over disagreements about COVID shutdowns.

West Covina officials have criticized the county health department’s COVID restrictions as a one-size-fits-all approach that may work for the second-largest city in the U.S., but not their suburb of about 109,500 people. West Covina plans to join Long Beach, Pasadena, and Berkeley as one of a small number of California cities with its own health agency. A date for the separation has not been set.

As in Douglas County, West Covina plans to contract some services to a private consultant, Transtech Engineers, that works mainly on city engineering projects and federal contracts, according to its website. Transtech officials did not respond to requests for comment.

West Covina Councilman Tony Wu and area family physician Dr. Basil Vassantachart are leading efforts to form the city’s own department. They hope L.A. County’s oversight of about 10 million people — “bigger than some states,” as Vassantachart noted — can be broken up into regional departments.

Amitabh Chandra, who directs health policy research at the Harvard Kennedy School of Government, said the private sector won’t necessarily have better answers to a public health problem. “It might be the case that they’re good at delivering on some parts of what needs to be done, but other parts still have to be done in-house,” Chandra said.

Jeffrey Levi, a professor of health policy and management at the George Washington University, suggests there are too many local health departments in the U.S. and there should be more regionalization, rather than splitting into smaller departments.

“It’s very hard to effectively spend money and build the foundational capabilities that are associated with a meaningful public health department,” Levi said. “Doing this just because of anger at something like a mask ordinance is really unfortunate.”

Levi noted that public health departments are responsible for everything from restaurant and septic system inspections to administering the Special Supplemental Nutrition Program for Women, Infants, and Children, or WIC, a federal food assistance program. If a department is not adequately resourced or prepared, residents could see lapses in food or water safety efforts in their community, Levi said.

“L.A. County Public Health Department is one of the most sophisticated, and one of the most robust health departments in the country,” Levi said. “You are losing access to just a wide, wide range of both expertise and services that will never be replicable at the local level. Never.”

“The public will be hurt in ways that are not instantly measurable,” he added.

The most recent major private-sector takeover of public health was a flop. A private nonprofit, the Institute for Population Health, took over Detroit’s public health functions in 2012 as the city was approaching bankruptcy.

The experiment failed, leaving a private entity unable to properly oversee public funding and public health concerns placed on the back burner amid the city’s economic woes. Residents also didn’t have a say in where the money went, and the staff on the city’s side was stripped down and couldn’t properly monitor the nonprofit’s use of the funds. By 2015, most services transferred back to the city as Detroit emerged from bankruptcy in 2014.

“That private institute thought it was going to issue governmental orders until it was informed it had no power,” said Denise Chrysler, who directs the Network for Public Health Law’s Mid-States Region at the University of Michigan School of Public Health.

In Colorado, Tri-County’s deputy director, Jennifer Ludwig, expressed concerns about Douglas County creating non-COVID programs essential to the functioning of a public health department.

“We have programs and services that many single-county health departments are not able to do just because of the resources that we can tap into,” Ludwig said. “Building that from scratch is a huge feat and will take many, many, many years.”

There are also practical benefits. A larger health department, according to Ludwig, is more competitive in securing grant funding, can attract and retain high-quality expertise like a data team, and can buy supplies in bulk.

But West Covina’s Wu accepts that the city will not be able to build its department overnight. “You have to start small,” he said.

Douglas County and West Covina face another key snag: hiring amid a national public health worker shortage. Douglas County officials say they are conducting a national search for an executive director who will determine the new health department’s staffing needs.

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

The announcement means Congress should be able to avert a government shutdown when a spending patch expires at midnight on Friday, though an additional patch until next week will have to be passed as well.

The $1.5 trillion government funding section of the bill includes the first round of earmarks in more than a decade, allowing members from both political parties to secure federal dollars for home-state projects. 

The overhauled program, now referred to as congressionally directed spending or community project funding, was brought back less than a year ago with members of both political parties requesting millions for projects ranging from addiction treatment programs to bridge repairs to agriculture programs. 

The new earmarks include more guardrails and oversight mechanisms than lawmakers had in place before House Republicans and Senate Democrats banned the former practice in 2011 following years of scandal. 

For example, funding cannot go to for-profit entities and the Government Accountability Office will audit the process annually. The total amount of spending on earmarks is now capped at 1%. 

In addition to funding for the whole of the federal government, the measure includes $13.6 billion for military and humanitarian assistance in Ukraine amid the Russian war and $15 billion in pandemic assistance for testing, therapeutics and vaccines. 

The $1.5 trillion government funding section of the package provides $782 billion, or a 6% increase, for defense and $730 billion, or a 6.7% increase, for domestic and foreign aid programs for the fiscal year that began on Oct. 1. 

The U.S. House is expected to vote on the  2,741-page measure Wednesday to send it to the Senate. President Joe Biden is expected to sign the measure into law once it reaches his desk.

But lawmakers will also vote on a stopgap spending bill to keep the government running through March 15 to give the Senate enough time to hold votes on the package. 

Senate Minority Leader Mitch McConnell said in a statement that he would be encouraging his colleagues to vote for the bill.

“The bipartisan product contains major wins for our national defense, for our friends in Ukraine, for the conscience rights of the American people, and for many other key priorities, and it keeps new left-wing poison pills out,” the Kentucky Republican said in a statement.

Acting White House Budget Director Shalanda Young said: “The bipartisan funding bill is proof that both parties can come together to deliver for the American people and advance critical national priorities.”

GOP lawmakers were able to keep the nearly 50-year-old Hyde amendment in the spending package after Democrats removed it from the original batch of House and Senate appropriations bills. 

The provision, as well as several others like it, bars the federal government from spending money on abortion with limited exceptions. 

Progressive Democrats have long sought to remove the funding prohibitions from the annual government funding measures, but this was the first fiscal year Democratic party leaders did so. 

Republicans said they wouldn’t agree to any funding measure that didn’t include the spending restriction, leading to it being added back into the final version of the bills Congress is set to pass in the coming days. 

House Appropriations Chair Rosa DeLauro, a Connecticut Democrat, said in a statement that the spending measure “delivers transformative federal investments to help lower the cost of living for working families, create American jobs, and provide a lifeline for the vulnerable.” 

The federal spending section of the bill has been in the works for months, though both political parties reached agreement on a “framework” for the deal just last month. 

Negotiations over assistance for Ukraine and the pandemic began a little over a week ago when the Biden administration told Congress that Ukraine needed about $6.4 billion in assistance. As Russia continued to bomb the country, killing civilians and sending more than 2 million people fleeing to Europe as refugees, the White House increased the request to $10 billion. Biden also asked Congress to include $22.5 billion in COVID-19 aid. 

White House wants $10 billion for Ukraine aid, $22.5 billion for more COVID help

The government spending bill wraps up the dozen annual government spending bills that fund federal departments and agencies. The package is supposed to pass before the start of the fiscal year on Oct. 1, but Congress rarely reaches agreement by the deadline. 

This year, lawmakers used three stopgap spending bills to keep money flowing at levels last agreed to during the Trump administration before coming to agreement this week. 

The White House said in a Statement of Administration Policy that it supported the package, in part, because it “would end a damaging series of short-term continuing resolutions that for months have undermined the Government’s ability to meet pressing challenges and would provide critical resources to invest in American workers and families and advance American leadership abroad.”

The funding packages, which generally get broad bipartisan support, also carry several additional bills with them. 

This year that includes a reauthorization of the Violence Against Women Act, which hasn’t been authorized since lawmakers allowed it to expire in December 2018. 

“The expiration of VAWA three years ago put many lives in jeopardy,” Senate Majority Leader Chuck Schumer said in a statement. “It is such good news that it is finally being reauthorized.” 

Cuando comience el período de inscripción abierta para adquirir cobertura médica en los mercados de seguros establecidos por la Ley de Cuidado de Salud a Bajo Precio, conocida como Obamacare, un grupo que antes no podía inscribirse será elegible por primera vez: los “Dreamers”. Ese es el nombre de los niños traídos a los Estados Unidos sin papeles que están bajo el programa de Acción Diferida para los Llegados en la Infancia (DACA).

Bajo una normativa de la administración Biden, que ha sido objeto de controversia en algunos estados, los beneficiarios de DACA podrán inscribirse para la cobertura del Obamacare y, si cumplen con los requisitos de ingresos, recibir subsidios para pagar sus primas.

Del medio millón de beneficiarios de DACA, el gobierno estima que alrededor de 100.000 que anteriormente no tenían seguro podrían inscribirse a partir del 1 de noviembre, fecha de inicio de la temporada de inscripción en todos los estados excepto Idaho.

Sin embargo, el destino de esta normativa sigue siendo incierto. Está siendo impugnada en un tribunal federal por Kansas y otros 18 estados, incluidos varios en el sur y el medio oeste, así como Montana, New Hampshire y Dakota del Norte.

Por otro lado, 19 estados y el Distrito de Columbia presentaron un escrito en apoyo a la normativa de la administración de Biden. Liderados por Nueva Jersey, estos estados incluyen a muchos en las costas este y oeste, como California, Colorado, Nevada, Nuevo México, Nueva York, Oregon y Washington.

La normativa, finalizada en mayo, aclara que aquellos que califican para DACA serán considerados como “presencia legal” para el propósito de inscribirse en lo planes médicos bao ACA, los cuales están abiertos a ciudadanos estadounidenses e inmigrantes con papeles.

“El cambio de normativa es muy importante, ya que corrige una exclusión errónea y de larga data de los beneficiarios de DACA para la cobertura de ACA,” dijo Nicholas Espíritu, director legal adjunto del National Immigration Law Center, que también ha presentado escritos en apoyo a este cambio.

El presidente Barack Obama estableció DACA en junio de 2012 mediante una acción ejecutiva para proteger de la deportación y proporcionar autorización de trabajo a algunos residentes sin documentos, que habían sido traídos al país de niños por sus familias. Esto si cumplían con ciertos requisitos, incluidos haber llegado antes de junio de 2007 y haber completado la escuela secundaria, estar asistiendo a la escuela o haber servido en las fuerzas armadas.

Los estados que impugnan la normativa de ACA dicen que causará cargas administrativas y de recursos a medida que más personas se inscriban, y que fomentará que más personas permanezcan en el país sin papeles. La demanda, presentada en agosto en el Tribunal de Distrito de EE.UU. para el Distrito de Dakota del Norte, busca posponer la fecha de entrada en vigencia de la normativa y anularla, argumentando que la expansión de la definición de “presencia legal” por parte de la administración Biden viola la ley.

El 15 de octubre, el juez de distrito de EE.UU., Daniel Traynor, nombrado en 2019 por el entonces presidente Donald Trump, escuchó los argumentos en el caso.

Los estados demandantes están presionando para que se actúe rápido, y es posible que se emita un fallo antes del inicio de la inscripción abierta a nivel nacional, dijo Zachary Baron, experto legal en la Facultad de Derecho de Georgetown, quien ayuda a administrar el O’Neill Institute Health Care Litigation Tracker.

Sin embargo, el panorama es complicado.

Para empezar, en una batalla legal como ésta, quienes presentan el caso deben demostrar el daño que se alega, como los costos adicionales que la normativa obligará a los estados a absorber. Solo hay alrededor de 128 beneficiarios de DACA en Dakota del Norte, donde se está llevando a cabo el caso, y no todos probablemente se inscribirán en el seguro de ACA.

Además, Dakota del Norte no se encuentra entre los estados que administran su propio mercado de inscripción. Depende del sitio federal cuidadodesalud.gov, lo que hace que sea más difícil cumplir con la carga legal.

“Aunque Dakota del Norte no gasta dinero para adquirir atención médica de ACA, aún están afirmando de alguna manera que están siendo perjudicados,” dijo Espíritu, del centro de leyes de inmigración, que representa a varios beneficiarios de DACA y a CASA, una organización sin fines de lucro de defensa de los inmigrantes, en oposición a los esfuerzos estatales por anular la normativa.

Durante la audiencia, Traynor se centró en este tema y señaló que un estado que administre su propio mercado podría ser un mejor lugar para un caso así. Ordenó a los demandados presentar más información antes del 29 de octubre, y a Dakota del Norte responder antes del 12 de noviembre.

El lunes 28 de octubre, el juez denegó una moción del gobierno federal que le solicitaba reconsiderar su orden de proporcionar al estado, bajo sello, los nombres de 128 beneficiarios de DACA que residen allí, con el fin de ayudar a calcular los costos financieros asociados con su presencia.

Además, es posible que el caso sea transferido a otro tribunal de distrito, lo que podría causar demoras en una decisión, según los abogados que siguen el caso.

El juez también podría tomar decidir en varias direcciones. Podría posponer la fecha de vigencia de la normativa, como se solicita en parte de la demanda, impidiendo que los beneficiarios de DACA se inscriban en Obamacare mientras se resuelve el caso. O podría dejar la fecha de vigencia tal como está mientras el caso avanza.

Con cualquiera de las opciones, el juez podría decidir aplicar el fallo a nivel nacional o limitarlo solo a los estados que impugnaron la normativa gubernamental, explicó Baron.

“El enfoque adoptado por diferentes jueces ha variado”, dijo Baron. “Ha habido una práctica de anular algunas disposiciones reglamentarias a nivel nacional, pero muchos jueces, incluidos jueces de la Corte Suprema, también han expresado preocupaciones sobre que jueces individuales puedan afectar la política de esta manera”.

A medida que el caso avanza, Espíritu dijo que su organización está alentando a los beneficiarios de DACA a inscribirse apenas comience el período de inscripción a nivel nacional.

“Es importante inscribirse lo antes posible”, dijo, agregando que organizaciones como la suya continuarán monitoreando el caso y dando actualizaciones si la situación cambia. “Sabemos que obtener acceso a atención médica buena y asequible puede transformar la vida de las personas”.

Este caso que impugna la normativa es completamente separado de otro caso, presentado por algunos de los mismos estados que se oponen a la normativa de ACA, que busca terminar por completo el programa DACA. Ese caso actualmente está en el proceso de apelación en un tribunal federal.

Julie Appleby:
jappleby@kff.org,
@Julie_appleby

En una sofocante tarde de julio de 2020, Belinda Ramones recibió una llamada informándole que su hermano estaba en el hospital. La llamada fue de una mujer de la empresa de jardinería en Florida en donde había comenzado a trabajar esa semana, la empresa Davey Tree Expert Co. Cuando llegó, “mi hermano estaba hinchado de pies a cabeza”, dijo.

Dos días después, su hermano, José Leandro-Barrera, murió a los 45 años por una insuficiencia renal aguda causada por un golpe de calor, según el informe del médico forense del condado de Hillsborough. Su temperatura en la ambulancia había sido a 108 grados Fahrenheit (42 °C), según el informe.

El informe también describía las circunstancias previas a su muerte, según lo registrado por una enfermera. En el trabajo, Leandro-Barrera le informó a su supervisor que no se sentía bien, y el supervisor le dijo que se sentara en uno de los vehículos hasta que se sintiera mejor. Mientras estaba allí, “se orinó, tuvo actividad convulsiva” y perdió la conciencia.

“El empleado sufrió agotamiento por calor mientras hacía trabajo de jardinería”, indicó una investigación del incidente realizada por la Administración de Seguridad y Salud Ocupacional (OSHA). La agencia impuso una multa de $9,639 a la empresa Davey Tree Expert Co. La empresa no respondió a las solicitudes de comentarios.

Sin regulaciones nacionales sobre la prevención de enfermedades y muertes relacionadas con el calor, OSHA tiene dificultades, en general, para proteger a los trabajadores antes de que sea demasiado tarde, dijo Paloma Rentería, vocera del Departamento de Trabajo.

Los trabajadores están sufriendo cada vez más, a medida que los veranos se vuelven progresivamente más calurosos debido al cambio climático.

Pero los investigadores en políticas de salud y salud ocupacional afirman que estas muertes se pueden prevenir. Los empleadores pueden salvar vidas ofreciendo suficiente agua y descansos, y dándoles tiempo a los nuevos trabajadores para adaptarse al calor extremo.

Esta es la lógica detrás de las reglas nacionales propuestas que el presidente Joe Biden puso en marcha en 2021, con el objetivo de proteger a unos 36 millones de trabajadores expuestos al calor extremo. La Oficina de Estadísticas Laborales cuenta un promedio de 480 muertes de trabajadores por exposición al calor cada año. Sin embargo, estas son “vastas subestimaciones”, según OSHA, ya que el estrés térmico es un factor subyacente que generalmente no se registra en los informes médicos.

La organización de defensa Public Citizen estima que hasta 2.000 trabajadores en el país mueren por el calor cada año, según extrapolaciones de datos sobre lesiones por calor.

Ambas estimaciones son alarmantes, dijo Linda McCauley, decana de la Facultad de Enfermería de la Universidad de Emory e investigadora en salud ocupacional. “Nadie debería ir a trabajar esperando que podría morir”, dijo.

Las normas propuestas —un estándar de calor de OSHA— alcanzarán un hito el 30 de diciembre, cuando cierra el período de comentarios públicos. Pero es poco probable que se finalicen antes de que Biden deje el cargo.

La vicepresidenta Kamala Harris probablemente continuaría con las normas sobre el calor si gana la presidencia el próximo mes, dijo Jordan Barab, quien fue subsecretario adjunto de OSHA durante la administración Obama. Ella impulsó regulaciones sobre el calor en California en 2020.

Si Donald Trump gana, las normas se estancarían, predice Barab. En general, los republicanos se han opuesto a regulaciones de seguridad en el lugar de trabajo en los últimos 20 años, argumentando que son costosas para las empresas y los consumidores.

Y durante la primera administración de Trump, la cantidad de inspectores de OSHA encargados de monitorear la seguridad en el trabajo alcanzó un mínimo histórico en los 48 años de historia de la agencia. Las inspecciones de lugares de trabajo relacionadas con el estrés térmico se redujeron a la mitad durante el mandato de Trump, según un análisis del National employment Law Project.

Las normas de OSHA requerirían que los empleadores proporcionen agua potable fresca en abundancia y sombra o aire acondicionado para los descansos cuando las temperaturas superen los 80.6° Fahrenheit (27° C). Por encima de los 89.6° Fahrenheit (32° C), los empleadores tendrían que ofrecer descansos pagados de 15 minutos cada dos horas.

Dos aspectos adicionales del estándar abordan problemas que han sido pasados por alto y que contribuyen a las muertes por calor en el trabajo. Más del 70% de las muertes por el calor ocurren durante la primera semana en que el trabajador comienza en el empleo. Y el atraso en la atención médica es un tema común.

“Debemos dejar de decirle a las personas que se quejan de sentirse a punto de desmayarse que vayan a sentarse en el auto o que tomen un descanso”, dijo McCauley. “Los descansos son necesarios para prevenir el problema, pero una vez que alguien tiene síntomas, necesita ayuda rápida”.

Las normas propuestas requieren que los empleadores permitan a los nuevos trabajadores tiempo para aclimatarse a las altas temperaturas e implementen protocolos, como un sistema para ayudarse entre compañeros, para que los trabajadores reciban atención médica rápidamente tan pronto como muestren signos de enfermedad por calor, como mareos, confusión y calambres.

Para cuando un equipo médico de emergencia llegó a ayudar a un trabajador en julio de 2021, había dejado de respirar, según un comunicado de prensa del Departamento de Trabajo. Un supervisor en la empresa de restauración ecológica EarthBalance lo había visto más temprano ese día, y estaba “sudando mucho, sus manos temblaban y parecía confundido”. Descansó. “Solo 30 minutos después, el supervisor regresó y lo encontró inconsciente”.

Esa noche, Gilberto Macario-Giménez murió en el hospital, dijo un informe del caso del médico forense. Señaló que “el fallecido se había sobrecalentado” y atribuyó su muerte a una enfermedad cardíaca e hipertensión. El calor puede agravar esas condiciones.

OSHA investigó la situación. Multó a EarthBalance con $9,216, encontrando que “el empleador no garantizó que una persona adecuadamente capacitada para brindar primeros auxilios a los empleados estuviera trabajando en un área donde no había enfermería”.

EarthBalance no respondió a las solicitudes de comentarios.

OSHA ha recibido al menos 12.980 comentarios sobre sus propuestas publicadas en el registro federal. Una mujer escribió sobre su primo que murió mientras despejaba arbustos en un rancho en Texas cuando las temperaturas superaron los 100° Fahrenheit (37° C): “Tenía solo 34 años. No había agua ni descansos”.

Después que termine el período de comentarios en diciembre, OSHA realizará una audiencia pública, incluirá cambios y finalizará la regla. Si Harris es presidenta, dijo Barab, la agencia podría finalizar el proceso para 2026.

Para que la norma funcione, el Congreso necesitaría financiar adecuadamente a OSHA, para que pueda contratar personal que enseñe a los empleadores cómo implementar los estándares, y suficientes investigadores para hacer cumplir las normas.

Varios grupos de la industria se han opuesto al estándar. Un único conjunto de normas no es justo cuando los climas y trabajos varían ampliamente, además de la capacidad de los trabajadores para tolerar el calor, escribió la Associated General Contractors of America en una declaración en línea.

Algunos legisladores republicanos han llamado a la norma una extra limitación del gobierno. Rick Roth, representante republicano del estado de Florida, dijo a Al Jazeera que los trabajadores están presionando por descansos pagados porque “no quieren trabajar tan duro”. Si no se sienten seguros, podrían cambiar de trabajo. “Vayan a trabajar para otra persona”, dijo.

Los críticos también dicen que las regulaciones costarán a los empleadores. Pero un análisis de UCLA de los reclamos de compensaciones de trabajadores en California sugiere que un estándar nacional sobre el calor ahorraría dinero en general. El estudio estimó el costo de las lesiones relacionadas con el calor entre $750 millones y $1,25 mil millones anuales solo en California, incluidos gastos médicos, pérdida de salarios y reclamos por discapacidad.

Dado que seis estados tienen conjuntos de reglas variables para reducir las enfermedades relacionadas con el calor —California, Colorado, Maryland, Minnesota, Oregon y Washington—, los investigadores y representantes sindicales han podido ver dónde necesitan fortalecerse las políticas.

Un problema con la aplicación es que OSHA depende en gran medida de que los empleados reporten riesgos. Un estudio encontró que solo el 14% de casi 600 trabajadores agrícolas encuestados en California sabían sobre el período de aclimatación y cuánta agua necesitaban cuando las temperaturas eran altas.

Aunque Florida no tiene regulaciones específicas sobre el calor, Dominique O’Connor, de la Asociación de Trabajadores Agrícolas de Florida, dijo que el mayor obstáculo para garantizar la seguridad ocupacional es que los trabajadores tienen miedo de que los despidan por presentar una queja ante OSHA.

Esto es especialmente cierto para los trabajadores agrícolas con visas H-2A, que permiten a los no ciudadanos cubrir trabajos temporales. Debido a que estos trabajadores dependen de sus empleadores no solo para permanecer en el país, sino a menudo también para transporte y vivienda, las represalias de los empleadores serían un cambio de vida. “Este verano hablamos con trabajadores H-2A a quienes solo se les daba agua sucia en el trabajo”, dijo. “Les dijeron que pretendieran que era café”.

Si llega a emitirse, es probable que los líderes de varios estados controlados por republicanos se opongan al estándar federal. En abril pasado, el gobernador de Florida, Ron DeSantis, aprobó una legislación que bloquea a los gobiernos locales de exigir a los empleadores que ofrezcan agua y sombra a los trabajadores cuando las temperaturas aumentan.

Y la decisión de la Corte Suprema de anular la “doctrina Chevron” este año puede alentar a los empleadores a desafiar la capacidad de OSHA para hacer cumplir las normas.

Durante décadas, la doctrina Chevron había requerido que los tribunales se delegaran a la experiencia de las agencias reguladoras al interpretar regulaciones, pero el fallo de la Corte Suprema terminó con eso. “Estamos en territorio desconocido”, dijo Barab.

Jeremy Young, productor senior de Fault Lines en Al Jazeera English, colaboró con este informe.

Health care is suddenly front and center in the final sprint to the presidential election, and the outcome will shape the Affordable Care Act and the coverage it gives to more than 40 million people.

Besides reproductive rights, health care for most of the campaign has been an in-the-shadows issue. However, recent comments from former President Donald Trump and his running mate, Ohio Sen. JD Vance, about possible changes to the ACA have opened Republicans up to heavier scrutiny.

More than 1,500 doctors across the country recently released a letter calling on Trump to reveal details about how he would alter the ACA, saying the information is needed so voters can make an informed decision. The letter came from the Committee to Protect Health Care, a national advocacy group of physicians.

“It’s remarkable that a decade and a half after the ACA passed, we are still debating these fundamental issues,” said Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes KFF Health News. “Democrats want to protect people with preexisting conditions, which requires money and regulation. Republicans have looked to scale back federal regulation, and the byproduct is fewer protections.”

The two parties’ tickets hold starkly different goals for the ACA, a sweeping law passed under former President Barack Obama that set minimum benefit standards, made more people eligible for Medicaid, and ensured consumers with preexisting health conditions couldn’t be denied health coverage.

Vice President Kamala Harris, who previously backed a universal health care plan, wants to expand and strengthen the health law, popularly known as Obamacare. She supports making permanent temporary enhanced subsidies that lower the cost of premiums. And she’s expected to press Congress to extend Medicaid coverage to more people in the 10 states that have so far not expanded the program.

Trump, who repeatedly tried and failed to repeal the ACA, said in the September presidential debate that he has “concepts of a plan” to replace or change the legislation. Although that sound bite became a bit of a laugh line because Trump had promised an alternative health insurance plan many times during his administration and never delivered, Vance later provided more details.

He said the next Trump administration would deregulate insurance markets — a change that some health analysts say could provide more choice but erode protections for people with preexisting conditions. He seemed to adjust his position during the vice presidential debate, saying the ACA’s protections for preexisting conditions should be left in place.

Such health policy changes could be advanced as part of a large tax measure in 2025, Sen. Tom Cotton (R-Ark.) told NBC News. That could also open the door to changes in Medicaid. Conservatives have long sought to remake the health insurance program for low-income or disabled people from the current system, in which the federal government contributes a formula-based percentage of states’ total Medicaid costs, to one that caps federal outlays through block grants or per capita funding limits. ACA advocates say that would shift significant costs to states and force most or all states to drop the expansion of the program over time.

Democrats are trying to turn the comments into a political liability for Trump, with the Harris campaign running ads saying Trump doesn’t have a health plan to replace the ACA. Harris’ campaign also released a 43-page report, “The Trump-Vance ‘Concept’ on Health Care,” asserting that her opponents would “rip away coverage from people with preexisting conditions and raise costs for millions.”

Republicans were tripped up in the past when they sought unsuccessfully to repeal the ACA. Instead, the law became more popular, and the risk Republicans posed to preexisting condition protections helped Democrats retake control of the House in 2018.

In a KFF poll last winter, two-thirds of the public said it is very important to maintain the law’s ban on charging people with health problems more for health insurance or rejecting their coverage.

“People in this election are focused on issues that affect their family,” said Robert Blendon, a professor emeritus of health policy and political analysis at Harvard. “If people believe their own insurance will be affected by Trump, it could matter.”

Vance, in a Sept. 15 interview on NBC’s “Meet the Press,” tried to minimize this impact.

“You want to make sure that preexisting coverage — conditions — are covered, you want to make sure that people have access to the doctors that they need, and you also want to implement some deregulatory agenda so that people can choose a health care plan that fits them,” he said.

Vance went on to say that the best way to ensure everyone is covered is to promote more choice and not put everyone in the same insurance risk pool.

Risk pools are fundamental to insurance. They refer to a group of people who share the burdens of health costs.

Under the ACA, enrollees are generally in the same pool regardless of their health status or preexisting conditions. This is done to control premium costs for everyone by using the lower costs incurred by healthy participants to keep in check the higher costs incurred by unhealthy participants. Separating sicker people into their own pool can lead to higher costs for people with chronic health conditions, potentially putting coverage out of financial reach for them.

The Harris campaign has seized on the threat, saying in its recent report that “health insurers will go back to discriminating on the basis of how healthy or unhealthy you are.”

But some ACA critics think there are ways to separate risk pools without undermining coverage.

“Unsurprisingly, it’s been blown out of proportion for political purposes,” said Theo Merkel, a former Trump aide who now is a senior research fellow at the Paragon Health Institute, a right-leaning organization that produces health research and market-based policy proposals.

Adding short-term plans to coverage options won’t hurt the ACA marketplace and will give consumers more affordable options, said Merkel, who is also a senior fellow at the Manhattan Institute. The Trump administration increased the maximum duration of these plans, then Biden rolled it back to four months.

People eligible for subsidies would likely buy comprehensive ACA plans because — with the financial help — they would be affordable. Thus, the ACA market and its protections for preexisting conditions would continue to function, Merkel said. But offering short-term plans, too, would provide a more affordable option for people who don’t qualify for subsidies and who would be more likely to buy the noncompliant plans.

He also said that in states that allowed people to buy non-ACA-compliant plans outside the exchange, the exchanges performed better than in states that prohibited it. Another option, Merkel said, is a reinsurance program similar to one that operates in Alaska. Under the plan, the state pays insurers back for covering very expensive health claims, which helps keep premiums affordable.

But advocates of the ACA say separating sick and healthy people into different insurance risk pools will make health coverage unaffordable for people with chronic conditions, and that letting people purchase short-term health plans for longer durations will backfire.

“It uninsures people when they get sick,” said Leslie Dach, executive chair of Protect Our Care, which advocates for the health law. “There’s no reason to do this. It’s unconscionable and makes no economic sense. They will hide behind saying ‘we’re making it better,’ but it’s all untrue.”

Harris, meanwhile, wants to preserve the temporary expanded subsidies that have helped more people get lower-priced health coverage under the ACA. These expanded subsidies that help about 20 million people will expire at the end of 2025, setting the stage for a pitched battle in Congress between Republicans who want to let them run out and Democrats who say they should be made permanent.

Democrats in September introduced a bill to make them permanent. One challenge: The Congressional Budget Office estimated doing so would increase the federal deficit by more than $330 billion over 10 years.

In the end, the ability of either candidate to significantly grow or change the ACA rests with Congress. Polls suggest Republicans are in a good position to take control of the Senate, with the outcome in the House more up in the air. The margins, however, will likely be tight. In any case, many initiatives, such as expanding or restricting short-term health plans, also can be advanced with executive orders and regulations, as both Trump and Biden have done.

Stephanie Armour:
sarmour@kff.org,
@StephArmour1

“We’re bankrupting a lot of hospitals by forcing these hospitals to provide care for people who don’t have the legal right to be in our country.”

Sen. JD Vance (R-Ohio) during a Sept. 17 rally

During a recent presidential campaign rally in Wisconsin, Sen. JD Vance (R-Ohio) was asked how a Trump administration would protect rural health care access in the face of hospital closures, such as two this year in Eau Claire and Chippewa Falls.

In response, he turned to immigration.

“Now, you might not think that rural health care access is an immigration issue,” said Vance, former President Donald Trump’s running mate. “I guarantee it is an immigration issue, because we’re bankrupting a lot of hospitals by forcing these hospitals to provide care for people who don’t have the legal right to be in our country.”

More than 150 rural hospitals have closed or eliminated inpatient services since 2010, researchers at the University of North Carolina-Chapel Hill reported. Losing a hospital can resonate throughout a community — reducing access to timely care and disrupting the local economy.

The federal government has made efforts to keep the far-flung facilities afloat, but it’s not been an easy problem to solve.

What Is Plaguing Rural Hospitals?

Experts said Vance’s statement implies that immigrants who are in the country illegally strain the resources of these hospitals, which often operate on thin margins, by taking time and energy away from other patients without paying their bills.

We contacted both Vance and Trump campaign staff members for additional information. They did not respond.

Experts on hospital financing and industry representatives generally disagreed with Vance’s assertion, noting that many other factors figure in closures.

“When we speak with our rural hospital members, that is not what we hear,” said Shannon Wu, director of payment policy at the American Hospital Association, a trade group of more than 5,000 hospitals around the country.

Brock Slabach, chief operating officer of the National Rural Health Association, said border state hospitals face challenges treating immigrants who are in the country illegally. “But I’ve never, in my discussions, had anyone link it directly to a hospital closure,” he said.

The specific situations that lead a rural hospital to close its doors are unique to each facility, researchers said, but many face some of the same stressors.

Rural hospitals tend to have low patient volumes, which presents its own set of problems. They’re frequently located in small communities, and some residents may choose to travel to hospitals in bigger cities where they can get more complex care, what researchers call “hospital bypass.”

That small number of patients can cause financial losses at small rural hospitals, said Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, a national health care payment and delivery systems policy center.

Hospitals have fixed costs, such as for running emergency departments, and need to have a high enough patient volume to cover them, he said.

“If a patient comes into the ED and doesn’t have insurance or can’t pay, it doesn’t really increase the cost to the hospital very much at all because the physician is already there,” he said, using an abbreviation for emergency department.

Rural hospitals treat a higher share of patients covered by Medicare and Medicaid compared with urban hospitals, according to the American Medical Association. The public insurance programs for older and low-income Americans generally pay providers less than private insurers do.

Nevertheless, Medicare is “one of the better payers” for small rural hospitals, Miller said. That’s partly because facilities with a special “critical access hospital” designation get paid more by Medicare — and, in some states, Medicaid.

Hospital industry officials and some experts say Medicare Advantage plans’ rising popularity has also hurt rural hospitals’ bottom lines because the private insurance companies that offer the plans tend to be less reliable payers than traditional Medicare.

For starters, the negotiated rates paid by Advantage plans can be lower, which is especially noticeable for those critical access facilities. Advantage plans also introduce extra levels of expensive, staff-intensive administrative burdens to ensure payment.

“They’ll deny the claim or say the patient really didn’t need that service through prior authorization, and so the hospitals don’t get paid for the service from someone who has insurance,” Miller said.

The insurance industry trade group AHIP pushed back on the assertion that Medicare Advantage plans harm rural hospitals, citing a federally supported study saying the plans actually increase rural hospital financial stability.

But the study did not compare actual payments between Medicare Advantage and traditional Medicare plans and looked at only 14 states.

People lacking legal immigration status generally cannot obtain Medicaid or Medicare coverage. But a provision within Medicaid law does allow some immigrants in the country illegally to temporarily obtain coverage, said Hayden Dublois, data and analytics director for the think tank Foundation for Government Accountability.

Medicaid, which pays less than Medicare and private insurance, “is not exactly a financial boon for hospitals,” and this could be some of what Vance is referring to, Dublois said.

In data from a few states, Dublois found a rise in people enrolling in Medicaid without being able to verify their immigration status. But his research hasn’t looked specifically at how this population might affect rural hospitals’ financial viability.

Some states have acted in recent years to expand health coverage to people in the country illegally — offering insurance to more than 1 million low-income immigrants.

One of those states, California, has had nine hospitals close or end in-patient services since 2005.

People may be able to pay out-of-pocket for care, researchers said, or may have access to private insurance through an employer.

Covering the costs for the uninsured is only one financial stressor rural hospitals face, said George Pink, deputy director of the North Carolina Rural Health Research Program.

“Is that going to be enough to drive a hospital into bankruptcy? Probably not,” he said.

A financial decline can take years, Pink said. As losses mount, hospitals can be forced to sell property or other assets, draw down any financial reserves, and max out their credit.

“This is not an overnight phenomenon,” he said.

Our Ruling

Vance said providing care for immigrants without legal status was “bankrupting” rural hospitals and forcing them to close.

Although that population is more likely to be uninsured, living in the country illegally does not mean people lack the ability to pay for health care — especially if they live in states that offer them insurance coverage.

Research shows many factors contribute to rural hospital closures — not solely financial losses from providing care for those without insurance, whether those people are migrants in the country illegally or U.S. citizens.

We rate Vance’s statement False. 

PBS NewsHour, “WATCH LIVE: Vance Addresses Campaign Rally in Eau Claire, WI,” Sept. 17, 2024.

HSHS Hospital Sisters Health System, “HSHS Sacred Heart Hospital and HSHS St. Joseph’s Hospital Closure Information,” accessed Sept. 26, 2024.

Cecil G. Sheps Center for Health Services Research, the University of North Carolina-Chapel Hill, “Rural Hospital Closures,” accessed Sept. 27, 2024.

GAO, “Rural Hospital Closures: Affected Residents Had Reduced Access to Health Care Services,” Dec. 22, 2020.

The Journal of Rural Health, “The Impact of Rural General Hospital Closures on Communities — A Systematic Review of the Literature,” Nov. 20, 2023.

Rural Health Information Hub, “Rural Emergency Hospitals (REHs),” accessed Sept. 30, 2024.

KFF Health News, “Federal Program To Save Rural Hospitals Feels ‘Growing Pains,’” Jan. 16, 2024.

Microsoft Teams interview, Shannon Wu, director of payment policy at the American Hospital Association, Oct. 1, 2024.

Zoom interview, Brock Slabach, chief operating officer, National Rural Health Association, Oct. 1, 2024.

Cecil G. Sheps Center for Health Services Research, the University of North Carolina-Chapel Hill, “Patterns of Hospital Bypass and Inpatient Care-Seeking by Rural Residents,” accessed Oct. 1, 2024.

Zoom interview, Harold Miller, president and CEO, Center for Healthcare Quality and Payment Reform, Sept. 26, 2024.

American Medical Association, “Issue Brief: Payment & Delivery in Rural Hospitals,” accessed Oct. 15, 2024.

Rural Health Information Hub, “Critical Access Hospitals (CAHs),” accessed Sept. 30, 2024.

KFF, “Medicare Advantage Enrollment, Plan Availability and Premiums in Rural Areas,” Sept. 7, 2023.

KFF Health News, “Tiny, Rural Hospitals Feel the Pinch as Medicare Advantage Plans Grow,” Oct. 23, 2023.

Email interview, James Swann, director of communications and public affairs, AHIP, Oct. 21, 2024.

Medicaid.gov, “Implementation Guide: Citizenship and Non-Citizen Eligibility,” accessed Oct. 10, 2024.

Zoom and email interview, Hayden Dublois, data and analytics director, the Foundation for Government Accountability, Oct. 1, 2024.

The Commonwealth Fund, “How Differences in Medicaid, Medicare, and Commercial Health Insurance Payment Rates Impact Access, Health Equity, and Cost,” Aug. 17, 2022.

KFF Health News, “States Expand Health Coverage for Immigrants as GOP Hits Biden Over Border Crossings,” Dec. 28, 2023.

Phone interview, George Pink, deputy director, North Carolina Rural Health Research Program, Sept. 30, 2024.

KFF, “State Health Coverage for Immigrants and Implications for Health Coverage and Care,” May 1, 2024.

Exactech, a Florida device manufacturer that faces more than 2,000 state and federal lawsuits from patients who allege the company sold defective hip and knee implants, filed for bankruptcy protection Tuesday.

The Gainesville-based company said in a statement it was restructuring and would be sold to an investor group of private equity and “alternative asset” firms, which would provide about $85 million in financing to fund the company’s operations.

Darin Johnson, Exactech’s president and chief executive officer, said in the statement that the device company faces “unsustainable liabilities associated with knee and hip litigation related to the packaging recalls we voluntarily initiated between 2021 and 2022.” The company said it would continue to operate during the bankruptcy proceedings.

“We take our commitment to patient well-being very seriously and have provided substantial out-of-pocket patient reimbursements and surgeon support for related expenses,” Johnson said.

The bankruptcy proceedings in federal court in Delaware will pause the lawsuits from patients seeking damages.

The surprise action dismayed lawyers representing injured patients.

“Exactech’s bankruptcy filing is a slap in the face to all the joint-implant patients and doctors who trusted the company. A medical device company that sells products for implantation in the human body has a special responsibility for public health,” said Joe Saunders, a Florida attorney who has sued the company on behalf of injured patients.

Saunders said the bankruptcy “serves to cover up public disclosure of the company putting profits ahead of safety.”

Injured patients were expecting one of the first jury trials against the company to begin in December in the circuit court in Alachua County, Florida. But the bankruptcy filing “stops the public trial and conceals the truth about the company’s conduct,” Saunders said.

Exactech, which grew over three decades from a small device manufacturer into a global entity, was the subject of a KFF Health News investigation published in October 2023.

The investigation found that, in hundreds of instances, the company took years to report adverse events to a federal database that tracks device failures.

Many of the lawsuits allege that the company’s knee and hip implants had an “unacceptable failure and complication rate.” Exactech has denied the allegations, and the company had no comment on the lawsuits.

Exactech began a series of recalls of artificial knees, hips, and ankles, starting in August 2021. Exactech initially blamed a packaging defect dating back as far as 2004 for possibly causing the plastic component to wear out prematurely in about 140,000 implants.

The KFF Health News analysis of more than 300 pending cases in Alachua County found that surgeons removed about 200 implants after less than seven years, far sooner than the 15 to 20 years these products typically last.

“I’m so angry. How did they [Exactech] think they are not responsible for this?” said Sue Sacher, 76, a New Jersey resident. She said she had her right knee replaced with an Exactech implant in 2006 and the left one done three years later, both at the Hospital for Special Surgery in New York.

Since then, she’s had both implants replaced.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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