Uno de los visitantes habituales de la clínica, un hombre con densas flechas negras tatuadas en sus brazos, espera en la acera para limpiar las agujas.

“Soy Arrow”, dijo, presentándose. “Un gusto”.

La unidad móvil en el condado de Miami-Dade es parte de IDEA Exchange, el único programa de intercambio de jeringas legal que opera en el estado. Pero el gobernador republicano Ron DeSantis firmó una nueva ley que apunta a cambiar esto.

Los intercambios de jeringas han sido legales en muchos otros estados durante décadas, pero los estados del sur, liderados por republicanos, como Florida, han comenzado recientemente a adoptar esta intervención de salud pública.

La legalización de los espacios para intercambiar jeringas en todo el estado se produce cuando Florida se enfrenta a un enorme problema con la heroína y el fentanilo. Cuando las personas comparten agujas sucias para inyectarse drogas, están en alto riesgo de propagar infecciones de transmisión sanguínea como el VIH y la hepatitis C. Durante años, Florida ha tenido las tasas más altas de VIH del país.

Aun así, dijo Arrow, él y cada usuario que conoció siempre ponían las drogas primero. Las agujas limpias fueron una reacción tardía.

“De vez en cuando, usaba la de otra persona y era un viaje emocionante, preguntándome si iba a contraer algo o no. Pero estoy bendecido. Tengo 57 años y no tengo nada “, dijo Arrow a un reportero en la clínica móvil, un año atrás.

Kaiser Health News acordó no usar su nombre completo debido a que es usuario de drogas ilegales.

“Ahora puedo usar una jeringa limpia cada vez”, dijo.

El experimento de Miami

Según los (CDC), los intercambios de agujas previenen la propagación de virus entre los usuarios de drogas inyectables.

Pero defensores que quieren ofrecer intercambios de jeringas enfrentan desafíos. Por ejemplo, llevar un montón de jeringas para repartir sin recetas puede violar las leyes de utensilios utilizados para consumir drogas.

Muchos estados diseñaron marcos legales hace décadas para permitir el intercambio de agujas como una intervención de salud pública. Pero en Florida, era ilegal operar intercambios. Luego, en 2016, la Legislatura estatal otorgó un permiso temporal al condado de Miami-Dade para realizar un programa piloto durante cinco años.

“Esto es más que un simple intercambio de jeringas”, dijo el senador demócrata Oscar Braynon. “Esto se ha convertido en un centro itinerante de emergencia y salud”.

En tres años de operaciones, el programa piloto de Miami ha retirado de circulación más de un cuarto de millón de agujas usadas, según informes que el programa presentó al Departamento de Salud de Florida. Al repartir Narcan, , el intercambio ha prevenido más de mil sobredosis. El programa también ofrece a los clientes pruebas para detectar el VIH y la hepatitis C. Finalmente, conecta a las personas con la atención médica y la rehabilitación.

Este año, Braynon presentó el para permitir que el resto de los condados de Florida autoricen programas similares.

“Hemos logrado que ahora sea más fácil para las personas con VIH obtener atención médica, y tenemos muchas que nunca hubiéramos sabido que estaban infectadas, y que hubieran infectado a muchas otras que están tomando sus medicamentos”, dijo el doctor Hansel Tookes, quien encabeza el programa piloto de intercambio de jeringas de Miami.

Tookes estuvo en Tallahassee, la capital del estado, en mayo, cuando el proyecto de ley de expansión aprobó su votación final, una posibilidad muy remota en la legislatura dominada por conservadores que, sin embargo, fue aprobada por un margen abrumador. Dijo que pasó el vuelo de regreso a Miami mirando por la ventana.

“Miré Florida durante todo el viaje”, dijo, “y tuve una sensación abrumadora como, ‘Oh, Dios mío, logramos lo imposible y vamos a salvar a muchas personas en este estado'”.

¿Por qué la reducción de daños venció a la política?

Hace seis años, el senador estatal republicano Rob Bradley votó “no” después de considerar una propuesta para intercambiar jeringas.

“Estás tratando de asegurarte que la persona tenga una jeringa limpia, lo que está superando la idea de que la persona infringe la ley”, declaró en 2013.

Esta es la principal objeción de los conservadores: la preocupación que estos programas promuevan el abuso de drogas ilegales. Responder a este escepticismo con datos ha sido fundamental para cambiar la mentalidad de los legisladores.

Décadas de investigación muestran que los intercambios de agujas no fomentan el uso indebido de drogas, y que disminuyen otros riesgos de salud para las personas que son vulnerables. Es parte de un enfoque de salud pública conocido como “reducción de daños”.

En Miami, el proyecto piloto de intercambio de agujas también se ha ganado el apoyo de la policía.

Oficiales dicen que es un alivio saber que más usuarios de drogas inyectables mantienen sus jeringas en , proporcionados por el intercambio, para desechar de forma segura las jeringas sucias.

“Ahora, para nuestros oficiales, cuando están haciendo una revisión… ese contenedor de objetos punzantes realmente te protege de una jeringa suelta”, dijo Eldys Díaz, oficial ejecutivo del jefe de policía de Miami. “Eso es una fuente extraordinaria de seguridad para nosotros”.

Este año, cuando Bradley volvió a escuchar la discusión sobre el proyecto de ley de intercambio de jeringas, tuvo una respuesta diferente.

“Solo quiero decir que cuando comencé mi carrera en el Senado, voté en contra del proyecto piloto, y me equivoqué”, dijo mientras votaba por el proyecto de ley esta vez. “Y los resultados hablan por sí mismos. Es una muy buena política pública”.

El proyecto de ley fue aprobado por unanimidad en el Senado de Florida y por una votación de 111-3 en la Cámara de Representantes. Entró en vigencia el lunes 1 de julio.

Arrow y su futuro

Si no fuera por los tatuajes que se expanden por sus brazos, hoy sería difícil reconocer a Arrow como el hombre que una vez durmió debajo de los puentes de la autopista. Tiene algo de carne en sus huesos. Se ve más saludable durante una visita a una clínica donde los clientes de intercambio de agujas reciben atención de seguimiento, pero ha sido un año difícil.

En mayo del año pasado, la novia de Arrow murió a causa de una infección cardíaca, una afección grave que puede afectar a las personas que se inyectan drogas. Después de eso, dijo Arrow, tuvo una sobredosis intencional. Sobrevivió gracias al Narcan del intercambio de agujas.

Pero siguió consumiendo.

Arrow dijo que no recuerda mucho de ese período, pero sí recuerda haber usado tanta heroína que se quedó sin jeringas nuevas entre las visitas al intercambio. Así que agarró las agujas usadas de otras personas.

Y luego dio positivo para VIH y hepatitis C.

Tookes y sus colegas lanzaron a Arrow otro salvavidas: le consiguieron un espacio en un hospital mientras estaba en rehabilitación.

Ahora Arrow luce una cadena de llaveros de Narcóticos Anónimos.

“Mi cadena de sobriedad”, explicó sobre los enlaces. “Tengo fichas de 30 días, 60 días y 90 días”, dijo.

El VIH de Arrow está bajo control. Y se conectó con los servicios de salud para las personas que viven con VIH, incluida la obtención de medicamentos que curan su hepatitis C.

Ahora, se enfoca en mantenerse lúcido, un día a la vez. Lleva unos seis meses sobrio.

Tookes, Braynon y otros partidarios esperan que los intercambios adicionales de jeringas en Florida brinden a más personas la oportunidad de recuperarse de la adicción y protegerse de enfermedades transmitidas por jeringas.

Esta historia es parte de una asociación que incluye WLRN, NPR y Kaiser Health News.

Ñî¹óåú´«Ã½Ò•îl 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 .

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One of the clinic’s regular visitors, a man with heavy black arrows tattooed on his arms, waited on the sidewalk to get clean needles.

“I’m Arrow,” he said, introducing himself. “Pleasure.”

This mobile unit in Miami-Dade County is part of the IDEA Exchange, the only legal needle exchange program operating in the state. But Florida’s Republican governor, Ron DeSantis, signed a new law last week that aims to change that.

Needle exchanges have been legal in many other states for decades, but Southern, Republican-led states like Florida have only recently started to adopt this public health intervention.

The timing of the statewide legalization of needle exchanges comes as Florida grapples with a huge heroin and fentanyl problem. When people share dirty needles to inject drugs, it puts them at high risk for spreading bloodborne infections like HIV and hepatitis C. For years, Florida has had America’s highest rates of HIV.

Even so, Arrow said, he and every user he knew always put the drugs first. Clean needles were an afterthought.

“Every once in a while, I did use someone else’s and that was a thrill ride — wondering whether or not I was going to catch anything. But I’m blessed; I’m 57 and I don’t have anything,” Arrow told a reporter at the mobile clinic over a year ago.

Kaiser Health News agreed not to use his full name because of his illegal drug use.

“Now I can shoot with a clean needle every time,” he said.

The Miami Experiment

According to the , needle exchanges prevent the spread of viruses among users of injection drugs.

But the advocates who want to offer needle exchanges face challenges. For example, carrying around loads of needles to hand out without prescriptions can violate drug paraphernalia laws.

Many states mapped out legal frameworks decades ago to allow needle exchanges as a public health intervention. But in Florida, it was illegal to operate exchanges. Then, in 2016, the state legislature gave Miami-Dade County temporary permission to pilot a needle exchange program for five years.

“This is more than just a needle exchange,” said Democratic state Sen. Oscar Braynon.

“This has become a roving triage and health center.”

In three years of operation, Miami’s pilot program has pulled more than a quarter-million used needles out of circulation, according to reports the program filed with the Florida Department of Health. By handing out Narcan — a — the exchange has prevented more than a thousand overdoses. The program also offers clients testing for HIV and hepatitis C. Finally, the program connects people to medical care and drug rehab.

This year, Braynon introduced to allow the rest of Florida’s counties to authorize similar programs.

“We have made it so easy for people to get into HIV care now, and we have so many people who we never would have known were infected — and would have infected countless other people — who are on their medications,” said Dr. Hansel Tookes, who heads Miami’s needle exchange pilot program.

Tookes was in Tallahassee, the state capital, in May when the expansion bill passed its final vote — a long shot in the conservative-dominated legislature that nonetheless passed by an overwhelming margin. He said he spent the return flight home to Miami staring out the window.

“I looked down at Florida the entire ride,” he said, “and I just had this overwhelming feeling like, ‘Oh, my God, we just did the impossible and we’re going to save so many people in this state.'”

Why Harm Reduction Trumped Politics

Six years ago, Republican state Sen. Rob Bradley cast a “no” vote after considering a proposal for needle exchanges.

“You’re trying to make sure the person has a clean needle, which is outweighing the idea of the person breaking the law,” he declared in 2013.

This is the primary objection of conservative lawmakers: the concern that these programs promote illegal drug abuse. Responding to this skepticism with data has been central to changing lawmakers’ minds.

Decades of research shows that needle exchanges do not encourage drug abuse, and that they lower other health risks for people who are vulnerable and often hard to reach. It’s part of a public health approach known as “harm reduction.”

In Miami, the needle exchange pilot project has also earned the support of law enforcement.

Officers say it’s a relief to know more injection drug users are keeping their syringes in special , provided by the exchange, to safely dispose of dirty needles.

“Now, for our officers, when they’re doing a pat-down … that sharps container is really protecting you from a loose needle,” said Eldys Diaz, executive officer to the Miami police chief. “That’s an extraordinary source of comfort for us.”

This year, when Bradley heard discussion of the needle exchange bill again, he had a different response.

“I just want to say, when I started my career in the Senate, I voted against the pilot project — and I was wrong,” he said as he voted for the bill this time. “And the results speak for themselves. It’s very good public policy.”

The bill passed unanimously in the Florida Senate and by a 111-3 vote in the Florida House. It took effect Monday.

Arrow Points To His Future

If it weren’t for the tattoos running down his arms, it would be hard today to recognize Arrow as the man who once slept under highway overpasses. His skin is now clear, and he has some meat on his bones. He looks healthier during a visit to a clinic where needle exchange clients get follow-up care, but it’s been a rough year.

In May of last year, Arrow’s girlfriend died from a heart infection — a serious condition that can happen to people who inject drugs. After that, Arrow said, he overdosed on purpose. Narcan from the needle exchange brought him back.

But he kept using.

Arrow said he doesn’t remember a lot from that period but does remember using so much heroin that he ran out of fresh needles between visits to the exchange. So he grabbed other people’s used needles.

And then he tested positive for HIV and hepatitis C.

Tookes and his colleagues threw Arrow another life raft: They got him an inpatient drug treatment bed.

Now Arrow sports a string of keychains from Narcotics Anonymous.

“My chain of sobriety,” he said of the links. “I got 30-days, 60-days and 90-days chips,” he said.

Arrow’s HIV is under control. And he connected with health services for people living with HIV, including getting medication that cured his hepatitis C.

Now, he’s focused on staying sober, one day at a time. He has been sober for about six months.

Tookes, Braynon and other supporters hope additional needle exchanges across Florida will give more people the chance to recover from addiction — and protect themselves from needle-borne illnesses.

This story is part of a partnership that includes , and Kaiser Health News.

Ñî¹óåú´«Ã½Ò•îl 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 .

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This story can be republished for free (details).

When Florida Gov. Rick Scott made free Zika testing available to all pregnant Floridians through the , I was one of the more than 2,200 women who took him up on the offer.

My station’s main studios are five blocks south of the Wynwood Zika , an area that authorities are recommending pregnant women avoid (though the advisory was  to a less dire warning on Monday). As it turned out, I had been inside the suspected transmission zone before we knew the risks.

So on the morning of Aug. 12, I went to my obstetrician’s office, gave blood and urine samples and was told that it would take about seven to 10 business days to get my results.

Four and a half weeks later, I was still waiting. I had plenty of company.

My colleague has been helping me cover the story, whenever it veers into an area where the Centers for Disease Control and Prevention has advised pregnant women to avoid. Stein covered a Miami Beach town hall I didn’t attend. There, she met Joseph Magazine, who pleaded with officials to help his wife get her Zika test results back. She was more than five months pregnant, had experienced Zika-like symptoms a month earlier, and was waiting to hear if she had been infected.

Press releases and other communications from the Florida health department officials have repeatedly insisted it takes one to two weeks to get results.

But at another town hall, after some pushing, Dr. Lillian Rivera, head of the Miami-Dade County Department of Health, said women may wait longer. “It could be four weeks, it could be five weeks,” Rivera said. “We are preparing them for that.”

But if the second test is positive, or inconclusive somehow, then the woman’s samples are sent to the CDC for an even more specialized test to confirm it’s Zika and not dengue or another virus that can cause false positives.

As of last week, Florida had sent 174 tests to the CDC for clarification, including the tests of people who aren’t pregnant. That total doesn’t explain the backlog that snared me.

Obstetrician , with the University of Miami and Jackson Health System, said it’s helpful that all pregnant women in Florida can be tested. But getting timely test results is important, too.

“If someone’s early first trimester or second trimester and we delay disclosure because we don’t have a result by two weeks, four weeks, six weeks, eight weeks — that may be long enough for them to be out of the window of being able to terminate that pregnancy,” she said.

Florida law restricts abortion access . Later-term abortions are also more complicated procedures and more emotionally fraught for parents.

Delays in testing results can change the way doctors screen the newborns of women who are still waiting on their Zika test results, Curry said. “Do we do more invasive, more aggressive testing? Do we do blood tests and urine tests and a spinal tap on the child?”

I spoke to Curry after I had been waiting more than a month for my results and that image jars me: a spinal tap on my newborn because of a bureaucratic backlog on test results?

This is when I started to get nervous and angry.

Zonnia Knight, a fellow pregnant South Floridian, compares the waiting period for the test results to being told there are spiders in the room.

“You find yourself scratching, or looking around, swatting off ghosts and stuff,” she said. “To me, there was a mosquito everywhere.”

Knight waited three weeks with those ghosts before her Zika results came back. She was negative.

Another pregnant woman, Tracy Towle Humphrey, went to a private lab for her test and bypassed the health department. Without insurance, those tests can range from about $150 to almost $800.

Humphrey’s insurance covered it, though. Within one week, she got her negative results back.

But she said for that week, she had trouble sleeping. She would wake up in the middle of the night “thinking, ‘Oh my gosh, what if it’s positive? What are we going to do?'”

After four and a half weeks, I called the Florida Department of Health.

I didn’t identify myself as a reporter. I was afraid that might affect my ability to get information on my own records. I was repeatedly told the health department doesn’t give out results over the phone and they’ll be sent to my doctor.

But after explaining a couple of times that I just wanted to know where my test was, I ended up talking to someone in the local epidemiology department who said she might be able to look up my test. She did, and I learned my test results were completed in the state lab in Jacksonville on Aug. 19 and Aug. 26.

So my completed tests were sitting there, I learned, for more than two weeks, and neither I nor my doctor had been informed of the results.

“Your story is completely consistent with my understanding,” said Dr. David Andrews, who runs the pathology laboratories at Jackson Health System and is on faculty at the University of Miami’s med school.

He told me he’s had upward of 900 pregnant women waiting on their Zika test results. The backlog is so large, he can’t even make a good calculation on the average turnaround time. “It is my sense that most of these specimens have been tested and are being tested in a reasonable amount of time, but the bottleneck appears to be getting us back the reports,” Andrews said.

Mara Gambineri, a spokesperson for Florida’s health department, sent an email that didn’t specifically respond to my question about why it takes so long to release results once the tests are completed:

“The department has been working with area hospitals and providers, particularly in Miami-Dade County, to ensure doctors are receiving test results quickly and communicating the information with their patients. We continue to work to improve and streamline the process.”

Another spokesperson named Sarah Revell said in the same exchange of emails:

“The department continues to dedicate significant resources to our public health labs and we have contracted with a private lab to assist with processing Zika tests quickly and accurately. Florida is the first and only state to offer such extensive resources to pregnant women and we are constantly working to improve our process.”

On Wednesday, Sept. 14, Gov. Scott announced the CDC is sending seven more people to help out with labs and testing “in order to ensure pregnant women get results back faster.”

On Friday, Sept. 16, a few hours after WLRN aired a story about the testing backlog and my wait, I got a call from the county health department asking for my doctor’s contact information. They released my test results to my obstetrician, who shared them with me: They are negative.

Kate Stein contributed to this report. This story is part of a partnership that includes , and Kaiser Health News.

Ñî¹óåú´«Ã½Ò•îl 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 .

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“I think it’s fair to say that most obstetricians had never heard of this virus a year ago,” said Curry, who is an assistant professor of obstetrics and gynecology at the University of Miami Miller School of Medicine and Jackson Memorial Hospital.

Curry, an obstetrician with a background in virology, volunteered to look into it for the rest of the staff.

“I knew from the get-go that it may end up being nothing, and just an interesting story out of Brazil, or it may end up being a reproductive game-changer — which is, I think, where we’re at right now,” Curry said.

“What we know about Zika is scary,” said Frieden during a news conference Monday, adding that this is the first time a mosquito bite has been known to lead to a birth defect.

“But in some ways what we don’t know about Zika is even more unsettling,” he said. “We don’t know the long-term impact Zika may have on children born to infected mothers who don’t have obvious signs of microcephaly, and these effects may only become apparent months or years in the future.”

Getting Tested

When Curry finds that a patient of hers has been to a place where there is active Zika transmission, she talks to her about getting a test — usually a blood test — that will determine whether she has the Zika antibodies or active virus in her system.

Those blood samples get sent to a state lab for testing. Curry said she’s been getting results back within one to three weeks.

And while pregnant women tend to be prepared for the anxious waiting periods that come with all sorts of routine testing for birth defects during pregnancy, nothing has quite the profile of Zika right now.

“I got a mosquito bite this morning and it’s probably the first time I ever cried over a mosquito bite,” said Zonnia Knight, who is due with her second child in mid-October.

Knight lives in Palmetto Bay and works at a communications firm in Coral Gables, but she’s spent time in Wynwood — including a dinner the night before pregnant women were told to avoid the area.

Knight called her midwife, who is giving her a prescription for a blood test that looks for antibodies that indicate whether or not she’s had a Zika infection.

Knight’s co-worker, Susie Gilden, is in her second trimester and is also asking for a Zika test because she’s visited Wynwood since June 15. Until now, Gilden and her doctor in Hollywood haven’t really talked about the virus.

“It would be nice to have some proactive communication to tell me what I should be doing,” said Gilden, who said she’s been “stalking” the CDC website and reading up on Zika online.

Positive For Zika

If a test in a pregnant woman does come back positive for having had Zika, her obstetrician has to add another layer of counseling and monitoring to her prenatal care.

“As with any time you deliver bad news, they’re really upset and they don’t hear everything you have to say initially,” said Curry, who arranges to disclose the results of Zika tests with her patients in person, rather than over the phone.

There’s a lot of conversation about next steps and, depending on the trimester, the mother’s option to terminate the pregnancy. Curry said it’s helpful to have a family member present.

“Or you may say, ‘listen, I’m going to write this down for you. I’m going to see you again next week. And we’re going to rehash this entire conversation when you’ve had a little bit of time to process things.’”

The mother may need to be retested for Zika antibodies. And her doctors will pay special attention to subsequent ultrasounds for abnormal head growth or calcifications in the baby’s brain.

“You see these little calcifications in the brain that are really indicators that you’re actually seeing loss of brain,” said Dr. Aileen Marty, professor of Infectious Diseases in the Department of Medicine at Florida International University’s Herbert Wertheim College of Medicine. She explained that the Zika virus appears to be attracted to stem cells that would otherwise become brain cells.

“And it basically tells the brain cell not to keep on maturing… It commits suicide and you lose those brain cells,” Marty said.

Microcephaly is just one of the symptoms of a baby harmed by Zika. Marty and other researchers say it appears the virus is also associated with deformities of the hands and feet, trouble developing reflexes for sucking and swallowing, and vision and hearing loss.

Born With Zika Injuries

At the end of June, the Florida Department of Health announced the state’s first birth of a child with Zika-related microcephaly. The baby’s mother had gotten Zika outside the United States. The state said it would connect the family to Early Steps, a state- and federally-funded program that provides resources — like speech therapy and other developmental interventions — to children up to 3 years old who are at risk for developmental delays.

“Understand that this is going to be a chronic, lifelong problem,” said Dr. Charles Bauer, a neonatologist and director of the Early Steps division in North Miami-Dade.

Bauer is part of a new team of doctors and therapists at UM and Jackson Health System who are coordinating to care for babies with Zika-related injuries. As soon as a baby with a known Zika exposure enters the nursery, Bauer and his colleagues will be able to start screening and developing a plan with the family.

“It’s a brand new area. We don’t know very much about it,” Bauer said. “We could be looking at lots of other things that wouldn’t show up until the baby is older and going to school — learning disabilities and things like that.”

There are 15 Early Steps sites across Florida. Bauer’s division sees around 3,500 infants and toddlers each year at a cost of about $7,500 per patient. The care is free to the family, though the program does bill insurance when possible.

Bauer said it’s too soon to know how Zika will affect his caseload. But he said he is concerned that Washington has yet to agree on funding for Zika.

“They need to stop playing politics,” he said. “It’s a big problem and it’s going to get bigger. As we know, it’s escalating every day.”

Against the backdrop of so much uncertainty, Bauer and other South Florida doctors are doing what they can to help expectant mothers and their babies.

“I picked Ob/Gyn because 95 percent of the time I am there for the happiest day of someone’s life,” Curry said. “But there’s a small fraction of what we do that’s really hard. It’s the conversations about miscarriages and stillbirths and birth defects.”

Curry is pragmatic. Even when she’s delivering bad news, she sees opportunity to help a patient through the experience.

“It’s about not losing the excitement of having a new baby, but also having a tempered expectation that we don’t totally know what the infection may mean for the development of the baby,” she said.

This story is part of a reporting partnership that includes , the and Kaiser Health News.

Ñî¹óåú´«Ã½Ò•îl 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 .

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This story can be republished for free (details).

“I believe that this contract honors and dignifies what you do every single day,” he told the school board members. It included bonuses for most teachers and it settled how to handle health care expenses after yet another year of rising costs.

“We know exactly what the district pays out in terms of claims, because we are the insurance company. There’s no profit to be made,” he said.

Like most large employers, the Miami-Dade school district is . It bears the financial risk of covering its own employees.

The school board’s reaction to the health care costs in the new contract was incredulous. They are an elected board and didn’t look forward to telling the teachers their prices were still going to go up. One board member after another questioned the rise in prices.

“Do we sit with our employees, knowing what their salaries are, and help them carve out the best options insurance-wise?” one asked. “Twenty-seven hundred more for his family’s health — can you comment on that?” asked another. Yet another lamented, “Our employees are tired of hearing about rising health care costs.”

This was not the conversation the superintendent expected.

“I thought we were coming here today [to] first and foremost celebrate something pretty remarkable,” he said.

Now, a year later with another new contract, the school board is still grappling with health care costs. Teacher contributions to insurance will mostly stay the same, but it means the district will absorb another 4 percent increase in costs.

Fedrick Ingram is head of the Miami-Dade County teacher’s union, which represents nearly 15,000 members.

Businesses and employees need to stop taking for granted that rising health care costs are inevitable because they make tradeoffs, Reinhardt says.

“Employees actually pay for what they think is company-provided insurance, by lower wages,” he says. But it’s so hard to get costs under control because the actual prices are secret.

Self-insured organizations like Miami-Dade County schools have to hire an insurance company to manage the claims process and negotiate rates with hospitals and doctors. But insurers and providers keep the rates secret, even from those employers hiring them.

Carvalho’s right: The district knows exactly what it pays overall for health care claims. What it doesn’t know is how much it’s paying to any one hospital or provider for a given service.

That means it doesn’t know who’s the most expensive provider, or who is the cheapest. That may drive prices higher for employees, Reinhardt says.

“It’s almost like blindfolding people, shoving them into Macy’s and saying, ‘Buy efficiently for a shirt.’ ” Reinhardt says. “Well, you come out with a pair of shorts.”

The school district is subject to the state’s open records laws, but Cigna, the insurance carrier they use for employees, refused to share accounts of what was actually paid out, citing trade secrets. Even though the county school district, which is taxpayer-funded, takes on that risk, it’s not allowed to see the contracted prices.

The district is seeking ways to get around the legal obstacles. It’s planning to shop for a service that can work with its limited and at least figure out average costs. Ideally, district officials say, they’d like to know enough about costs to offer incentives for employees who choose less expensive options.

Until there’s more transparency, Miami-Dade teacher’s union member, Cheryl Collier thinks the situation would offend even her second-graders.

“They would be angry that they are being forced pay for something, not really fully understanding the value of what they’re paying for,” she says.

It’s a lesson the school district and other employers are starting to learn.

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Believe it or not, that’s the easy part compared to figuring out what the overall cost of health care is.

Sal Morales of Miami bought insurance in March during the ACA’s first enrollment period on .

“I got my cards and it was like amazing,” Morales says, “like if I got an American Express Platinum card. That’s how I felt.”

Morales was unemployed at the time. Money was tight. And he knew he needed regular doctor visits to manage his high blood pressure. He diligently researched what he would get for the price before settling on a plan.

“Instead of me paying $560 [a month] for COBRA, I found out that I would have insurance for $145. I have a network deductible of $500,” Morales says. “My first three visits to a primary care physician, they’re zero dollars. Then it’s $5 out of my pocket.”

Morales understands his end of the health care equation, but what he sees doesn’t necessarily reflect what gets paid to doctors and hospitals for his care, says , president of the Florida Hospital Association.

Here’s how he breaks it down: “There’s one party, the hospital who provides the service. There’s a second party, the patient, who receives the service. And there’s a third party, the insurance, who pays for the service.”

“We’re identifying the procedure, we’re identifying the provider, the date of service and then making sure the amount, the member responsibility has to be in there,” Monzon says.

Wedged into that statement somewhere between the billing code and the member deductible, is a column for the amount paid.

This is the secret number the insurance company and the provider have worked into their contract, says Monzon. The industry terms are usually “adjusted rate” or “negotiated rate.”

In Florida Blue’s explanation of benefits to patients, it’s called simply “amount paid.”

To get a clearer sense of what health care costs, someone would have to collect enough of those statements from patients at all different hospitals with all different insurance.

There are companies and trying to do just that around the country. And Massachusetts has a law that says insurers some of these prices in a way that is accessible to patients.

But so far, that’s not happening in South Florida.

This story is part of a partnership that includes , the Miami Herald, and Kaiser Health News.

Ñî¹óåú´«Ã½Ò•îl 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 .

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For all of advertising to Latinos, that state has embraced the 2010 health law and is spending millions of dollars to get people to sign up. Florida is a different story. Florida has a of uninsured Latinos — almost 10 percent of all the country’s uninsured Hispanics who are eligible for health insurance under the Affordable Care Act live in the state.

Florida lawmakers rejected the Affordable Care Act from the beginning, even being party to the lawsuit to stop its implementation. When the ACA did become law, the state decided not to run its own exchange, and it has not expanded Medicaid. Gov. Rick Scott has come out in , but it’s unlikely the legislature will go along with it this session.

Florida is to anybody. In the absence of state outreach efforts, it’s up to the insurers — and other groups — to get the word out about Obamacare.

About a third of Florida’s Hispanics are not covered by insurance, yet insurers need them to sign up. They tend to be younger and healthier than the rest of the population, so insurers want them since they may pay more into the system than they use in services. Having healthy, young people on their rolls helps insurers balance the books.

, a large insurer, is trying to reach the population with a mix of old and new media. The company has developed an app for the mobile phone, since their research shows that’s how many Latinos access the Internet. Florida Blue is also partnering with Spanish-language bloggers and is forming a partnership with , a Hispanic drug store. They’ve also been working with community health centers where Latinos go to the doctor, since face-to-face interaction is critical to reaching this demographic.

Churches, health centers, from within the Latino community have also been working on a grassroots level.

Spanish-language television is also playing a key role in Florida. Univision is partnering with rival Telemundo for with President Barack Obama.

Univision’s Stephen Keppel says his network is embedding messages about health care into their variety programming, such as Sábado Gigante and .

Ñî¹óåú´«Ã½Ò•îl 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 .

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This story can be republished for free (details).