As Syphilis Invades Rural America, A Fraying Health Safety Net Is Failing To Stop It (KHN)
By Lauren Weber, Kaiser Health News When Karolyn Schrage first heard about the “dominoes gang” in the health clinic she runs in Joplin, Mo., she assumed it had to do with pizza. Turns out it was a group of men in their 60s and 70s who held a standing game night — which included sex with one another. They showed up at her clinic infected with syphilis. That has become Schrage’s new normal. Pregnant women, young men and teens are all part of the rapidly growing number of syphilis patients coming to the Choices Medical Services clinic in the rural southwestern corner of the state. She can barely keep the antibiotic treatment for syphilis, penicillin G benzathine, stocked on her shelves. Public health officials say rural counties across the Midwest and West are becoming the new battleground. While syphilis is still concentrated in cities such as San Francisco, Atlanta and Las Vegas, its continued spread into places like Missouri, Iowa, Kansas and Oklahoma creates a new set of challenges. Compared with urban hubs, rural populations tend to have less access to public health resources, less experience with syphilis and less willingness to address it because of socially conservative views toward homosexuality and nonmarital sex. In Missouri, the total number of syphilis patients has more than quadrupled since 2012 — jumping from 425 to 1,896 cases last year — according to a Kaiser Health News analysis of new state health data. Almost half of those are outside the major population centers and typical STD hot spots of Kansas City, St. Louis and its adjacent county. Syphilis cases surged at least eightfold during that period in the rest of the state. At Choices Medical Services, Schrage has watched the caseload grow from five cases to 32 in the first quarter of 2019 alone compared with the same period last year. “I’ve not seen anything like it in my history of doing sexual health care,” she said. Back in 1999, the Centers for Disease Control and Prevention had a plan to eradicate the sexually transmitted disease that totaled over 35,000 cases nationwide that year. While syphilis can cause permanent neurological damage, blindness or even death, it is both treatable and curable. By focusing on the epicenters clustered primarily throughout the South, California and in major urban areas, the plan seemed within reach. Instead, U.S. cases topped 101,500 in 2017 and are continuing to rise along with other sexually transmitted diseases. Syphilis is back in part because of increasing drug use, but health officials are losing the fight because of a combination of cuts in national and state health funding and crumbling public health infrastructure. “It really is astounding to me that in the modern Western world we are dealing with the epidemic that was almost eradicated,” said Schrage. Grappling With The Jump Craig Highfill, who directs Missouri’s field prevention efforts for the Bureau of HIV, STD and Hepatitis, has horror stories about how syphilis can be misunderstood. “Oh, no, honey, only hookers get syphilis,” he said one rural doctor told a patient who asked if she had the STD after spotting a lesion. In small towns, younger patients fear that their local doctor — who may also be their Sunday school teacher or basketball coach — may call their parents. Others don’t want to risk the receptionist at their doctor’s office gossiping about their diagnosis. Some men haven’t told family members they’re having sex with other men. And still more have no idea their partner may have cheated on them — and their doctors don’t want to ask, according to Highfill. It’s even hard to expect providers who haven’t seen a case of syphilis in their lifetime to automatically recognize the hallmarks of what is often called the “great imitator,” Highfill said. Syphilis can manifest differently among patients, but frequently shows up for a few weeks as lesions or rashes — often dismissed by doctors who aren’t expecting to see the disease. Since 2000, the current syphilis epidemic was most prevalent among men having sex with men. Starting in 2013, public health officials began seeing an alarming jump in the number of women contracting syphilis, which is particularly disturbing considering the deadly effects of congenital syphilis — when the disease is passed from a pregnant woman to her fetus. That can cause miscarriage, stillbirth or birth deformities. Among those rising numbers of women contracting syphilis and the men who were their partners, self-reported use of methamphetamines, heroin or other intravenous drugs continues to grow, according to the CDC. Public health officials suggest that increased drug use — which can result in a pattern of risky sex or trading sex for drugs — worsens the outbreaks. That perilous trend is playing out particularly in rural Missouri, argues Dr. Hilary Reno, an assistant professor of medicine at Washington University School of Medicine in St. Louis who is researching syphilis transmission and drug use in the state. Tracking cases from 2015 through June 2018, she found that more than half of patients outside of the major metropolitan areas of Kansas City and St. Louis reported using drugs. Less Money, More Problems Federal funding for STD prevention has stayed relatively flat since 2003, with $157.3 million allocated for fiscal year 2018. But that amounts to a nearly 40% decrease in purchasing power over that time, according to the National Coalition of STD Directors. In Missouri, CDC annual funding has been cut by over $354,000 from 2012 to 2018 — a 17% decrease even as the number of cases quadrupled, Highfill said. Iowa, too, has seen its STD funding cut by $82,000 over the past decade, according to Iowa Department of Health’s STD program manager George Walton. “It is very difficult to get ahead of an epidemic when case counts are steadily — sometimes rapidly — increasing and your resources are at best stagnant,” Walton said. “It just becomes overwhelming.” Highfill bemoaned that legislatures in Texas, Oregon and New York have all allocated state money to raise
Shrinking Medicaid Rolls In Missouri And Tennessee Raise Flag On Vetting Process
By Phil Galewitz, Kaiser Health News Tangunikia Ward, a single mom of two who has been unemployed for the past couple of years, was shocked when her St. Louis family was kicked off Missouri’s Medicaid program without warning last fall. She found out only when taking her son, Mario, 10, to a doctor to be treated for ringworm. When Ward, 29, tried to contact the state to get reinstated, she said it took several weeks just to have her calls returned. Then she waited again for the state to mail her a long form to fill out attesting to her income and family size, showing that she was still eligible for the state-federal health insurance program for the poor. Mario, who is in third grade, missed much of school in December because Ward could not afford a doctor visit without Medicaid. His school would not let him return without a doctor’s note saying he was no longer infected. In January, with the help of lawyers from Legal Services of Eastern Missouri, she was able to get back on Medicaid, take her son to a doctor and return him to school. “It was a real struggle as it seemed like everyone was giving me the runaround,” Ward said. “I am upset because my son was out of school, and that pushed him behind.” Ward and her children are among tens of thousands of Medicaid enrollees who were dropped by Missouri and Tennessee last year as both states stepped up efforts to verify members’ eligibility. Last year, Medicaid enrollment there declined far faster than in other states, and most of those losing coverage are children, according to state data. State health officials say several factors, including the improved economy, are behind last year’s drop of 7 percent in Missouri and 9 percent in Tennessee. But advocates for the poor think the states’ efforts to weed out residents who are improperly enrolled, or the difficulty of re-enrolling, has led to people being forced off the rolls. For example, Tennessee sent packets to enrollees that could be as long as 47 pages to verify their re-enrollment. In Missouri, people faced hours-long waits on the state’s phone lines to get help in enrolling. Medicaid enrollment nationally was down about 1.5 percent from January to October last year, the latest enrollment data available from the federal government’s Centers for Medicare & Medicaid Services (CMS). Herb Kuhn, president and chief executive of the Missouri Hospital Association, said the state’s efforts to verify Medicaid eligibility could be tied to an increase in the number of people without coverage that hospitals are seeing. “When we see over 50,000 children come off the Medicaid rolls, it raises some questions about whether the state is doing its verifications appropriately,” he said. “Those who are truly entitled to the service should get to keep it.” In 2018, Missouri Medicaid began automating its verification system for the state-federal insurance program for the poor. People who were identified as ineligible, for income or other reasons, were sent a letter asking them to provide updated documentation. Those who did not respond or could not prove their eligibility were dropped. The state does not know how many letters it sent or how many people responded, said Rebecca Woelfel, spokeswoman for the Missouri Department of Social Services, which oversees Medicaid. She said Missouri Medicaid enrollees were given 10 days to respond. Woelfel cited the new Medicaid eligibility system, the improved economy and Congress rescinding the federal tax penalty for people who lack insurance as factors behind the decline in enrollment. Missouri’s unemployment rate dropped from 3.7 percent in January 2018 to 3.1 percent in December as the number of unemployed people fell by about 17,000. Missouri Medicaid had almost 906,000 people enrolled as of December, down from more than 977,000 in January 2018, according to state data. About two-thirds of those enrolled are children or pregnant women. Timothy McBride, a health economist at Washington University in St. Louis who heads a Missouri Medicaid advisory board, said the state’s Medicaid eligibility system has made it too difficult for people to stay enrolled. Since low-income people move or may be homeless, their mailing addresses may be inaccurate. Plus, many don’t read their mail or may not understand what was required to stay enrolled, he added. “I worry some people are still eligible but just did not respond, and the next time they need health care they will show up with their Medicaid card and find out they are not covered,” McBride said. Tennessee’s Medicaid enrollment fell from 1.48 million in January 2018 to 1.35 million in December, according to state data. Tennessee Medicaid spokeswoman Kelly Gunderson credits a healthy job market. The state’s unemployment rate was relatively stable last year at under 4 percent. “Tennessee is experiencing a state economy that continues to increase at what appears to be near-historic rates, which is positively impacting Tennesseans’ lives and, in some cases, decreasing their need to access health insurance through the state’s Medicaid” program and the Children’s Health Insurance Program (CHIP), she said. She added that the state has a “robust appeals process” for anyone who was found ineligible by the state’s reverification system. The Tennessee Justice Center, an advocacy group, has worked with hundreds of families in the past year trying to restore their Medicaid coverage. The verification process will make “Medicaid rolls smaller and saves money, and that’s a poor way for the state to measure success,” said Michele Johnson, executive director of the nonprofit group. “But it’s penny-wise and pound-foolish” because it leads to people showing up at emergency rooms without coverage — and hospitals have to pass on those costs to everyone else. After rapid growth since 2014, when the Affordable Care Act expanded health insurance coverage to millions of Americans, Medicaid enrollment nationally started to fall, declining from 74 million in January 2018 to about 73 million in October, according to the latest enrollment data released by CMS. Missouri and Tennessee are among 17
Missouri Travel Nurse Needs Remain High In Wake Of Slow Flu Season
Missouri travel nurse needs have remained at a significantly high number throughout November and the first week of December, according to current market data. More than 140 travel nurse needs are active in the state, most of which are newer positions located in or around the St. Louis region, said Jennifer Pomietlo, a director of client advisory for LiquidAgents Healthcare. That includes cities like St. Charles, Chesterfield and Columbia. The most-needed specialties include medical-surgical, telemetry, ICU, step-down and OR nurses, with limited openings for other non-core or surgical specialties, Pomietlo said. Allied healthcare travel positions are also fairly limited, but certified surgical tech and rad tech opportunities are available. Contact Allie Evans with LiquidAgents Healthcare for more information about Missouri travel nurse jobs >> Flu is the main driver for hiring in the state, Pomietlo said. Normally, Missouri hospitals will aggressively hire in early fall because the state is one of a handful that typically see high levels of flu activity starting in November, according to Centers for Disease Control and Prevention records. This year’s flu season is off to a slower start for the state, with “minimal” influenza-like illness activity and sporadic spread, according to CDC data. A total of one death and 1,384 laboratory-positive influenza cases have been reported as of Nov. 24 to the Missouri Department of Health and Senior Services (DHSS). More than 300 cases were reported from the eastern region of the state, where St. Louis is located. Missouri hospitals are hiring in December in anticipation of a delayed surge in flu patient census in January and February, Pomietlo said. “They get hit hard by the flu in St. Louis, and it also hangs around longer in Missouri than in other places,” Pomietlo said. In the record-breaking 2017-18 flu season, Missouri reported 133,957 laboratory-confirmed cases of flu and more than 2,000 pneumonia and influenza-associated deaths, according to a DHSS press release. Other things travelers should know about Missouri Missouri is one of the 31 states that are part of the enhanced Nursing Licensure Compact, meaning nurses who have a compact license can work in the state without paying additional licensing fees. Travelers who don’t have a compact license can get a single state license at a low cost. The state board charges $55 for a license by endorsement or $45 by examination. Missouri is also a walk-through state, so nurses can get a temporary license within a day. You can find more Missouri licensing information on the state nursing board website.
Travel Jobs: Top 10 States for June, July Market Predictions
In our June traveler job market predictions, we talked about the “summer stall”—less new job postings, more competition for every job and more interest in atypical summer job states. Based on StaffDNA job board data, two of our predictions were on target. Job application volume increase by nearly 20 percent from May to June, marking the most active month since January. What we didn’t expect was for supply to match pace with demand. Hospital systems in many states, including popular summer destinations like California and Virginia, bounced back after the late-May and early-June slump. Part of this can be linked to vacation plans for permanent hospital staff, according to travel agency sales staff sources. As the regular staff takes off for the summer or cuts back on hours, that provides opportunities for travelers to fill the gaps. We expect for this market momentum to stay strong in July, as travelers who took time off in June will be planning ahead for the start of the school season in August or to find a fall contract in September. The back-to-school rush marks a yearly milestone for many travelers with children or grandchildren. They will typically take a break during the summer for childcare, and return to hospitals once the kids are back in school. “The experienced travelers know it can take four to six weeks to find and start a job, so they start the search for an agency and position mid-summer,” said Kate Quinn of LiquidAgents Healthcare. Let’s take a look at what we learned from our top markets for June. Rankings barely shift as travelers settle in for the summer While April and May saw a lot of “movement” in terms of where healthcare travelers applied across the country, ranking shifts were much more conservative in June, despite the high application volume. Most states moved up or down the list by 5 ranks or less, and five states—North Carolina, Pennsylvania, Nevada, Wisconsin and Washington—didn’t move at all. We expect the list to remain mostly stable for July, August and potentially in early fall, as traveler won’t start making big moves until we get closer to the holiday season. Michigan, Missouri, Virginia enter the Top 10 For the first time this year, Missouri joined the likes of Texas, California and Florida in the top 10, moving up two spots from May to No. 9. Virginia moved back up as anticipated, jumping up five ranks to No. 10 on the list. The state is both a top travel destination for summer 2018 and one of the top five highest paying travel nurse states in the U.S. Montana, Wyoming climb the charts; Connecticut drops to dead last Montana and Wyoming both moved up seven ranks to take the No. 41 and 42 slots, respectively, while Connecticut dropped 16 spots to the bottom of our list. Connecticut has consistently ranked in the bottom half of the list for job board applications. It’s also one of the most expensive states to work in as a traveler because of the high regional cost of living and low average pay packages. Interest in Maine uncertain as Medicaid expansion remains in flux Enrollment for the voter-approved Medicaid expansion was supposed to roll out on July 2, which would have provided a $500 million shot in the arm for healthcare funding in the state and coverage for more than 70,000 eligible recipients. Pending litigation surrounding the expansion has left the issue in limbo. A Maine judge forced Gov. Paul LePage to submit an expansion plan to the federal government by June 11, but LePage’s administration submitted an appeal for the ruling. While the appeal is pending, LePage also vetoed the expansion bill this week. Because of the political turmoil, it’s uncertain whether the expansion will have an impact on the Maine traveler job market as expected. June’s Top Markets Florida California Texas North Carolina Georgia South Carolina Michigan Pennsylvania Missouri Virginia Illinois Indiana Kentucky Tennessee Arkansas Arizona Nevada Idaho Oklahoma Iowa Wisconsin West Virginia New Mexico Maine Oregon Colorado Washington Hawaii Ohio Alabama Louisiana Maryland Mississippi New Jersey Alaska Utah Kansas Montana Wyoming Minnesota Massachusetts North Dakota New York District of Columbia Delaware Nebraska New Hampshire Rhode Island South Dakota Vermont Connecticut