Los gemelos de Nah Thu Thu Win necesitaban sus vacunas antes de empezar la guardería. Pero ella habla poco inglés y los niños no tienen seguro médico.

William Arce y Wanda Serrano se recuperaban de unas cirugías recientes; pero la pareja necesitaba ayuda para entender su cobertura y las facturas.

Engebretson, Win, Arce y Serrano tuvieron la suerte de contar con la ayuda de trabajadores de salud de Huron, una ciudad de 14.000 habitantes conocida por ser el lugar donde se celebra la feria estatal y donde se encuentra la escultura del faisán más grande del mundo.

Tres trabajadores del Huron Regional Medical Center ayudan a los pacientes a navegar el sistema de salud y a superar las barreras, como la pobreza o la falta de una Vivienda segura, que podrían impedirles recibir atención médica. Estos trabajadores de salud comunitarios también pueden proporcionar educación básica sobre la gestión de problemas crónicos, como la diabetes o el colesterol alto.

Los programas de trabajadores de salud comunitarios se extienden por todo Estados Unidos, incluyendo zonas rurales y ciudades pequeñas, a medida que los proveedores de servicios de salud y los gobiernos y invierten cada vez más en ellos.

Estas iniciativas llamaron la atención durante la pandemia de covid-19, y que mejoran la salud de las personas y el acceso a la atención preventiva, al tiempo que reducen las costosas visitas al hospital.

Según Gabriela Boscán Fauquier, supervisora de iniciativas de trabajadores de salud comunitarios en la National Rural Health Association, los programas que cuentan con estos trabajadores pueden superar obstáculos comunes en las zonas rurales, donde la población se enfrenta a y a  problemas de salud concretos.

Estos trabajadores son “una extensión del sistema de salud” y sirven de enlace “entre la formalidad del sistema y la comunidad”, explicó Boscán Fauquier.

Los programas suelen tener como base a sistemas hospitalarios o a centros de salud comunitarios. El salario promedio de los trabajadores es de $23 la hora, según la Oficina Federal de Estadísticas Laborales. Se suele referir a los pacientes luego que médicos han observado que van mucho a las salas de emergencias o enfrentan desafíos personales.

es uno de los estados que ha financiado recientemente programas de trabajadores de salud comunitarios, ha establecido requisitos de formación y ha aprobado el reembolso de Medicaid por sus servicios. El programa de certificación del estado exige aprobar un curso de 200 y 40 horas de prácticas.

El Huron Regional Medical Center puso en marcha la iniciativa en el otoño de 2022, luego de recibir una subvención federal de $228.000. Al programa ahora lo financia el hospital sin fines de lucro y los reembolsos de Medicaid.

La población ed Huron, una pequeña ciudad rodeada de campo, es mayoritariamente blanca no hispana. Pero miles de originarios de Karen, una minoría étnica de Myanmar, país del sudeste asiático, . Muchos son refugiados. La ciudad también cuenta con una importante población hispana procedente del Caribe, México, Centroamérica y Sudamérica.

Mickie Scheibe, una de las trabajadoras de salud de Huron, pasó hace poco por la casa de Kelly Engebretson. Este hombre de 61 años no había podido trabajar desde que le amputaron parte de una pierna por complicaciones de la diabetes.

Scheibe lo ayuda con “los trámites que hay que hacer”, como solicitar Medicaid, explicó Engebretson.

Le dijo a Scheibe que no sabía cómo iba a llegar a Sioux Falls, a dos horas en auto de su casa, para que le pusieran la prótesis. Scheibe, de 54 años, le dijo que lo ayudaría a encontrar un transporte seguro.

También invitó a Engebretson a un programa educativo sobre diabetes.

“Iré encantado”, respondió él, agregando que invitaría a su madre.

Ese mismo día, Sau-Mei Ramos, compañera de trabajo de Scheibe, visitó el apartamento donde viven William Arce y Wanda Serrano. Arce se estaba recuperando de una operación de corazón, mientras que Serrano había tenido una operación de rodilla y otra de hombro.

La pareja, ambos de 61 años, llegó hace tres años desde Puerto Rico para estar cerca de sus hijos en Huron. Ramos, que también es puertorriqueña, coordinó sus citas, respondió a sus preguntas sobre facturación y ayudó a Arce a encontrar un andador y un seguro complementario.

Ramos, de 29 años, le entregó a Arce un folleto sobre salud del corazón y le pidió que leyera la sección sobre angina de pecho, el dolor que se produce cuando no llega suficiente sangre al corazón.

“¿Qué entiende? “, le preguntó a Arce para saber si comprendía su enfermedad. Arce respondió que sabía qué era la angina de pecho y a qué síntomas debía estar atento.

Más tarde ese mismo día, Paw Wah Sa, la tercera trabajadora de salud comunitaria de la ciudad, se reunió con Nah Thu Thu Win, que llegó a Huron en febrero desde Myanmar con su marido y sus gemelos de 6 años. La familia Win, al igual que Sa, pertenecen a la comunidad Karen, perseguida por los militares de Myanmar, el país antes conocido como Birmania.

Win, de 29 años, suponía que los niños tendrían derecho a Medicaid. Pero, a diferencia de la mayoría de los demás estados, Dakota del Sur a los niños que han migrado legalmente a Estados Unidos. El padre de los niños espera poder incluirlos pronto en su seguro laboral.

Sa no quería que los niños tuvieran que esperar para recibir atención de salud. La joven, de 24 años, ya había llevado a los gemelos a una clínica dental móvil gratuita en Huron. Resultó que necesitaban un tratamiento dental más avanzado, que sólo podían recibir sin cargo en Sioux Falls. Sa los ayudó a hacer los trámites.

Muchos residents que pertenecen a la etnia Karen y los que proceden de zonas rurales de Latinoamérica tenían poco acceso a atención antes de venir a Estados Unidos, explicaron Sa y Ramos. Dijeron que una parte importante de su trabajo consiste en explicar qué tipo de atención está disponible y cuándo es importante buscar ayuda.

A veces, las tres trabajadoras llevan a sus clientes a hacer las compras, para enseñarles a entender las etiquetas y a identificar los alimentos saludables.

Boscán Fauquier, de la National Rural Health Association, afirmó que, dado que los trabajadores comunitarios conocen las culturas a las que atienden, pueden sugerir alimentos asequibles con los que los clientes están familiarizados.

La población de las zonas rurales de Estados Unidos se está reduciendo, pero el censo de 2020 mostró que se ha vuelto por la llegada de personas de minorías étnicas que entran a trabajar en industrias como la agricultura, el envasado de carne y la minería. Otros llegan atraídos por los bajos índices de delincuencia y las viviendas más económicas de las zonas rurales.

Boscán Fauquier señaló que muchos programas de trabajadores de salud para comunidades rurales atienden a personas de grupos minoritarios, que tienen que los blancos no hispanos de enfrentarse a barreras que les impiden el acceso a los servicios médicos.

Señaló los programas que atienden a las reservas de nativos americanos, a la región del Cinturón Negro del Sur y a las comunidades hispanohablantes, donde se conoce a las trabajadoras comunicatrias como “promotoras”. Pero estos trabajadores también atienden a comunidades rurales blancas no hispanas, como la de los Apalaches, afectadas por la crisis de los opioides.

Medicare, el programa federal de salud para adultos de 65 años o más, reembolsa los servicios de los trabajadores comunitarios . Boscán Fauquier dijo que los activistas de salud esperan que más programas estatales de Medicaid y permitan también el reembolso.

Engebretson comentó que se alegra de que haya trabajadores de salud comunitarios en todo Dakota del Sur, no sólo en las grandes ciudades.

Cuantos más “puedan llegar a las personas, mejor será”, dijo.

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Nah Thu Thu Win’s twin sons needed vaccinations before starting kindergarten. But she speaks little English, and the boys lacked health insurance.

William Arce and Wanda Serrano were recovering from recent surgeries. But the couple needed help sorting out their insurance and understanding their bills.

Engebretson, Win, Arce, and Serrano were fortunate to have someone to help.

They’re all paired with community health workers in Huron, a city of 14,000 people known for being home to the state fair and what’s billed as the world’s largest pheasant sculpture.

Three workers, employed by the Huron Regional Medical Center, help patients navigate the health system and address barriers, like poverty or unstable housing, that could keep them from getting care. Community health workers can also provide basic education on managing chronic health problems, such as diabetes or high cholesterol.

Community health worker programs are spreading across the U.S., including in rural areas and small cities as health providers and and governments increasingly invest in them. These initiatives gained attention during the coronavirus pandemic and to improve people’s health and access to preventive care while reducing expensive hospital visits.

Community health worker programs can address common barriers in rural areas, where people face and certain health problems, said Gabriela Boscán Fauquier, who oversees community health worker initiatives at the National Rural Health Association.

The workers are “an extension of the health care system” and serve as a link “between the formality of this health care system and the community,” she said.

The programs are often based at hospital systems or community health centers. The workers have a median pay of $23 an hour, according to the federal Bureau of Labor Statistics. Patients are typically referred to programs by clinicians who notice personal struggles or frequent visits to hospital emergency departments.

is among the states that have recently funded community health worker programs, developed training requirements for the workers, and approved Medicaid reimbursement for their services. The state’s certification program requires 200 hours of coursework and 40 hours of job shadowing.

Huron Regional Medical Center launched its initiative in fall 2022, after receiving a $228,000 federal grant. The program is now funded by the nonprofit hospital and Medicaid reimbursements.

Huron, a small city surrounded by rural areas, is mostly populated by white people. But thousands of Karen people — an ethnic minority from the Southeast Asian country of Myanmar — . Many are refugees. The city also has a significant Hispanic population from the Caribbean, Mexico, and Central and South America.

Mickie Scheibe, one of Huron’s community health workers, recently stopped by the house of client Kelly Engebretson. The 61-year-old hadn’t been able to work since he had part of his leg amputated, due to diabetes complications.

Scheibe helps with “the hoops you’ve got to jump through,” such as applying for Medicaid, Engebretson said.

He told Scheibe that he didn’t know how he was going to get to his prosthetic fitting in Sioux Falls — a two-hour drive from home. Scheibe, 54, said she would help find him a safe ride.

She also invited Engebretson to a diabetes education program.

“Put me down as a definitely absolutely,” he replied, adding that he’d invite his mother to tag along.

The same day, Scheibe’s co-worker Sau-Mei Ramos visited the apartment where William Arce and Wanda Serrano live. Arce was recovering from heart surgery, while Serrano was healing from knee and shoulder operations.

The couple, both 61, moved three years ago from Puerto Rico to be near their children in Huron. Ramos, who’s also from Puerto Rico, coordinated their appointments, answered their billing questions, and helped Arce find a walker and supplemental insurance.

Ramos, 29, handed Arce a pamphlet about heart health and asked him to read the section on angina, the pain that results when not enough blood flows to the heart.

“Qué entiende?” she said, asking Arce what he understood about his condition. Arce, speaking in Spanish, responded that he knew what angina was and what symptoms to watch for.

Later that day, Paw Wah Sa, the third community health worker in town, met with client Nah Thu Thu Win, who moved to Huron in February from Myanmar with her husband and twin 6-year-olds. The Win family, like Sa, are part of the local Karen community, whose people have been persecuted under the military rulers of Myanmar, the country formerly known as Burma.

Win, 29, had assumed the kids would qualify for Medicaid. But unlike most other states, South Dakota to children who legally immigrated into the U.S. The boys’ father hopes to eventually add them to his work-sponsored insurance.

Sa didn’t want the kids to have to wait for health care. The 24-year-old previously took the twins to a free mobile dental clinic in Huron. It turned out they needed more advanced dental work, which they could get free only in Sioux Falls. Sa helped make the arrangements.

Many Karen residents and people from rural parts of Latin America had little access to health care before moving to the U.S., Sa and Ramos said. They said a major part of their job is explaining what kind of care is available, and when it’s important to seek help.

The three community health workers sometimes take clients grocery shopping, to teach them how to understand labels and identify healthful food.

Boscán Fauquier, with the National Rural Health Association, said that because community health workers are familiar with the cultures they serve, they can suggest affordable food that clients are familiar with.

Rural America’s overall population is shrinking, but the 2020 census showed it has become as people representing ethnic minorities are drawn to jobs in industries such as farming, meatpacking, and mining. Others are attracted by rural areas’ lower crime rates and cheaper housing.

Boscán Fauquier said many rural community health worker programs serve people from minority groups, who are than white people to face barriers to health care.

She pointed to programs serving Native American reservations, the Black Belt region of the South, and Spanish-speaking communities, where the workers are called promotoras. But community health workers also serve rural white communities, such as those in Appalachia impacted by the opioid crisis.

Medicare, the federal health program for adults 65 or older, has been reimbursing community health worker services . Boscán Fauquier said advocates hope more state Medicaid programs and will allow reimbursement too.

Engebretson said he’s happy to see community health workers across South Dakota, not just in big cities.

The more they “can branch out to the people, the better it would be,” he said.

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Noneo is one of four community health representatives for the Fallon Paiute-Shoshone, which the tribe said includes about 1,160 enrolled members. The role primarily involves driving tribal members to their health appointments, whether in Fallon, a city of just under 10,000, or Reno, more than 60 miles west. Noneo said she and her colleagues have also taken patients as far away as Sacramento, California, and Salt Lake City, round trips of nearly 400 and 1,000 miles, respectively.

Public health experts contend the role Noneo and others like her fill is an integral part of ensuring people receive the care they need, especially for chronic illnesses, by helping close gaps in areas with medical provider shortages. Besides transporting patients to their appointments, community health representatives provide health education, patient advocacy, and more. Noneo said she and her colleagues spend a lot of time helping young mothers and elders, checking on the latter, taking them to get groceries, or delivering their medication.

Yet, most state Medicaid programs don’t recognize or pay for services offered by health workers, such as Noneo, who work on tribal lands. That’s despite their work being essentially the same as that of “community health workers” in nontribal communities, a classification many state Medicaid programs cover.

In Nevada, that disparity recently changed when the state began allowing workers on tribal lands to qualify for Medicaid reimbursement as community health workers. Tribal leaders say the Medicaid payments supplement existing personnel funding by covering the individual services the workers provide. That in turn should allow tribes to train and hire more community health representatives, which could expand health and support services for tribal members.

Only two other states, South Dakota and Arizona, treat community health representatives serving Native American populations as eligible for the same Medicaid reimbursement as their similarly named counterparts in nontribal areas, according to Michelle Archuleta, a community health representative program consultant for the federal Indian Health Service. However, she said, the tribes the CHRs work for have not begun billing the states’ Medicaid programs.

The Community Health Representative program, established by Congress in 1968, is among the nation’s . It’s jointly funded by each tribe and the IHS, an agency within the Department of Health and Human Services responsible for providing health care to members of federally recognized tribes. As of 2019, more than 1,600 of these tribal linchpins worked in the United States, according to the IHS.

Last year, the Centers for Medicare & Medicaid Services approved Nevada’s plan to make community health workers who complete training and certification requirements eligible for Medicaid reimbursement when they assist with chronic disease management and prevention.

And in December, leaders with the Nevada Community Health Worker Association helped tribes make sure their community health representatives would receive the necessary training for certification. The association would “fully support” tribal clinics submitting their community health representative training for recognition in the state and it would not require a change to state law, said Jay Kolbet-Clausell, program director for the group. For now, community health representatives are receiving double training to be able to file for Medicaid reimbursement.

Training and certification requirements for community health workers vary widely by state and employer, as workers are often hired by hospitals, local organizations, health departments, or federally qualified health centers. But a movement has been emerging across the country to bring more uniformity to those requirements and formalize the roles, said , a policy analyst with the Racial Equity and Health Policy program at KFF.

As part of this process, states are expanding coverage for community health workers under Medicaid. According to a , 28 of 47 states, and Washington, D.C., reported having policies that allow Medicaid reimbursement for services provided by community health workers. Arkansas, Georgia, and Hawaii did not respond to KFF’s survey.

“There’s a really robust evidence base that is growing every day that community health worker interventions can be effective in reducing health disparities, particularly in communities of color,” Haldar said.

Studies have also shown that community health worker programs are effective in for people with chronic conditions and that they .

Soon after Nevada implemented its program, about 50 community health representatives completed the requirements. Another cohort of 20 finished the curriculum later, said Kolbet-Clausell. The goal is for those who have completed the recent training to help their peers through it, they said.

Even before the tribal workers were included in the community health workforce, one of its greatest strengths was its diversity, Kolbet-Clausell said. In Nevada, the 2022 student group was made up of greater shares of people who are American Indian or Alaska Native, Hawaiian or Pacific Islander, Black, Hispanic, or from rural areas than the state’s general population. They said it’s likely one of the most diverse health programs in the state.

Community health representatives such as Noneo are typically tribal or community members themselves, which, public health experts say, allows them to connect more easily with the patients they serve and better connect them to health care.

For example, the first person she picked up that June morning was her cousin, who had a 6 a.m. dialysis appointment.

Kolbet-Clausell said they’re optimistic about the growing workforce and the support it’s getting from state leaders.

“Five, six years ago, there was a lot more resistance,” they said, because lawmakers saw the efforts to expand the community health workforce as simply spending more money. “But this actually just benefits rural communities as much as it benefits underserved urban communities. It serves everyone.”

Back in Fallon, Noneo reflected on her 27 years as a community health representative for her tribe as she prepares to retire in September. She has been there with her fellow tribal members through important and hard times in their lives — like driving an expectant mother to Reno to deliver a baby, taking people to receive treatment for mental health crises and addiction, and bringing patients to their dialysis treatments on her week off around Christmas so they wouldn’t miss their appointments.

The most challenging part of the job, she said, is experiencing the loss of someone she has regularly seen and provided years of services for.

“We all have compassion,” she said. “In this kind of job, you have to have that.”

After decades of shuttling patients, Noneo has the work down to a steady and familiar rhythm. Four hours after dropping off her cousin for dialysis, Noneo picked her up at the clinic as she dropped off the next dialysis patient. On a clipboard, she logged the hours and mileage for each appointment.

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A paramedic recently arrived at her doorstep again, but this time it wasn’t for an emergency. Jason Frye was there for a home visit as part of a new community paramedicine program.

Frye showed up in an SUV, not an ambulance. He carried a large black medical bag into Lane’s mobile home, which is on the eastern edge of the city, across from open fields and train tracks that snake between the region’s massive open-pit coal mines. Lane sat in an armchair as Frye took her blood pressure, measured her pulse, and hooked her up to a heart-monitoring machine.

“What matters to you in terms of health, goals?” Frye said.

Lane said she wants to become healthy enough to work, garden, and ride her motorcycle again.

Frye, a 44-year-old Navy veteran and former oil field worker, promised to help Lane sign up for physical therapy and offered to find an anti-slip grab bar for her shower.

Community paramedicine allows paramedics to use their skills outside of emergency settings. The goal is to help patients access care, maintain or improve their health, and reduce their dependence on costly ambulance rides and ER visits.

Such programs are expanding across the country, in , as health care providers, insurers, and state governments recognize the potential benefits to patients, ambulance services, and hospitals.

Gary Wingrove, a Florida-based leader in community paramedicine, said the concept took off in the early 2000s and now includes hundreds of sites. of 129 programs found that 55% operated in “rural” or “super rural” areas.

Community medicine can be helpful in rural areas where people have less access to health care, said Wingrove, chair of the International Roundtable on Community Paramedicine. “If we can get a community paramedic to their house,” he said, “then we can keep them connected to primary health care and all of the other services that they need.”

Frye works at Campbell County Health, a health care system based in Gillette, a city of about 33,000 in northeastern Wyoming. Leaders of the community paramedicine program plan to expand it into two adjacent, largely rural counties dotted with ranches and coal mines on the rolling prairie that stretches more than 100 miles from the Black Hills to the Bighorn Mountains.

Gillette serves as a medical hub for the region but has shortages of primary care doctors, specialists, and mental health services, according to a . People who live outside the city face additional barriers.

“A lot of them, especially older people, don’t want to come into town. And basically, those tiny communities don’t usually have health care,” Lane said. “I think it’s just kind of a pain for them to drive all the way into town, and unless they have a serious problem, I think they tend to just figure, ‘Well, it’ll work itself out.’”

Community paramedicine programs are customized to the needs and resources of each community.

“It’s not just a cookie-cutter-type operation. It’s like you can really mold it to wherever you need to mold it to,” Frye said.

Most community paramedicine programs rely on paramedics, but some also use emergency medicine technicians, nurses, social workers, and other professionals, according to the 2017 survey. Programs can offer home visits, phone check-ins, or transportation to nonemergency destinations, such as urgent care clinics and mental health centers.

Many programs support people with chronic illnesses, patients recovering from surgeries or hospital stays, or frequent users of 911 and the ER. Other programs focus on public health, behavioral health, hospice care, or post-overdose response.

Community paramedics can provide in-home vaccinations, wound care, ultrasounds, and blood tests.

They can offer exercise and nutrition tips, teach patients how to monitor their symptoms, and help with housing, economic, and social needs that can affect people’s health. For example, paramedics might inspect homes for safety hazards, provide a list of food banks, or connect lonely patients with a senior center.

Paramedics and patients said some rural residents struggle to access health care because of long distances, cost, lack of transportation, or dangerous weather. Some hesitate to seek help out of pride or because they don’t want to be a burden to others. Some limit trips to town during ranching and farming crunch times, such as calving and harvesting seasons.

Delayed care can let health problems fester until they become an emergency.

Advocates say providing in-home care, resources, and education can help patients reduce such crises and associated costs. Fewer emergencies mean fewer ambulance runs and hospital patients. That could help ambulance services and hospitals reduce costs and the time patients wait for help.

found that more studies are needed but that data so far suggests these programs reduce costs. It also found links to improved health outcomes and decreased use of ambulances and hospitals.

For example, a pilot program in Fort Worth, Texas, saw a 61% reduction in ambulance rides, . MedStar, the operator, made the effort permanent and says its 904 participants , saving an estimated $8.5 million over eight years.

But rural ambulance services, especially volunteer ones, can struggle to staff and fund community paramedicine programs.

Kesa Copps, a co-worker of Frye’s, previously worked as an emergency medical technician in Powder River County, Montana, which has fewer than 2,000 residents. Some people there must drive more than an hour to reach the nearest hospital. The area’s volunteer ambulance service started a community paramedicine program in 2019.

Copps said the program reduced hospital readmissions and extended some elderly patients’ ability to live at home before being admitted to a nursing facility. She visited patients between ambulance runs and had to leave early when a 911 call came in. That’s different from the Campbell County Health model, in which community paramedicine is a full-time position, not split with emergency work.

Adam Johnson, director of the Powder River ambulance service, said the community paramedicine program shut down in 2021 after everyone with the necessary training left the area. Johnson said paramedics are signing up for training to restart the program.

States are , and some require licensed paramedics to obtain extra training to work in the field.

Some ambulance services and health care organizations have piloted community paramedicine programs with the help of state or federal grants. If they find the service saves money, they may decide to continue the program and fund it themselves.

Private insurance companies are increasingly covering community paramedicine, Wingrove said. Wyoming and several other states allow operators to bill Medicaid for the services.

Advocates are now pushing Medicare to expand its of community paramedicine, Wingrove said. That would benefit Medicare patients and could spur more private insurers to offer coverage.

The Campbell County Health program’s home visits cost up to $240 per hour and are billed to Medicaid or Medicare, said Frye. That compares with more than $1,300 for an ambulance ride and thousands of dollars for a visit to a hospital ER.

Community paramedicine may soon expand in neighboring South Dakota, another largely rural state.

South Dakota ambulance services have experimented with community paramedicine and lawmakers to authorize and regulate it.

Eric Emery, the state representative who introduced the bill, plans to start a program on the sprawling, rural Rosebud Indian Reservation, where he works as a paramedic. He said the operation will focus on diabetes and mental health care.

Emery, a Democrat, said some people struggle to pick up their medication and attend appointments because they lack vehicles or gas money and there’s no public transportation to the hospital. He said some parents and grandparents raising children also struggle to find time to drive to appointments.

“They’re putting the needs of the younger generation or their grandkids before their own,” Emery said.

Back in Gillette, Frye also checked in on Linda Quitt, a 78-year-old facing diabetes, depression, and a lack of social support after her husband was hospitalized with dementia. Quitt said her husband was her walking buddy and helped care for her.

“I had him to wait on me, and now I have nobody,” Quitt said.

Frye said he would see if he could help start a senior walking group that Quitt could join. He told her that socializing can improve health.

“You’re not alone,” Frye told Quitt.

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“I would be getting maybe three to four a month,” recalled Lopez, a TB program supervisor with Cameron County’s health department.

In a matter of months, patients seeking care at the county’s two clinics dropped by half. “And then I wasn’t getting any at all,” he said.

As covid gripped the world’s attention, Lopez began to focus on a parallel concern: whether TB was being overlooked along the Texas-Mexico border.

“I knew there had to be TB cases out there; they just weren’t being found,” Lopez said in a recent interview.

Before 2020, advances to eradicate TB, which is spread person-to-person , were underway globally. It was considered by many public health experts to be a , since tools are available to identify and treat it. But the prevalence of the disease in Mexico, and immigration along the border, has made it a longtime health concern in these communities.

In areas with high immigrant traffic, such as Cameron County, TB is a serious health concern. Cameron sits at the southernmost tip of Texas, and each year millions of people cross to and from Mexico at the four border crossings in the Brownsville region. and largest city. In 2019, before covid, had an average TB incidence of 8.4 cases per 100,000 people — more than double that of the state overall, and nearly triple the national rate.

Since the pandemic began, though, some tuberculosis clinics in border areas have been performing fewer tests, receiving fewer referrals from local hospitals and providers, and treating fewer patients. Lopez and others who do this public health work every day on the ground agree it’s not likely less TB is circulating. Instead, they say, covid testing and treatment have claimed so much attention and energy that TB has been pushed off the radar, threatening to reverse decades of progress in eliminating it.

Lopez said his county’s tuberculosis department usually gets around 40 to 60 patients a year. “And then, all of a sudden, we went down to 20 during the covid pandemic,” he said. The numbers seem to be bouncing back. In 2022, Lopez said, the county’s clinics saw 35 TB patients. But that’s still lower than pre-pandemic levels.

Hidalgo County, which neighbors Cameron to the west, experienced a similar trend in 2020, when its number of confirmed TB cases was cut in half from the previous year, dropping from 71 cases to 36, according to Jeanne Salinas, tuberculosis program manager of the county health department. The county also performed hundreds fewer TB tests.

Since 2020, Salinas said, tuberculosis has been “overlooked” as a diagnosis for patients reporting “prolonged cough or cough with blood, losing weight, having fevers.” After covid became everyone’s overriding concern, these patients — who included new immigrants as well as people who regularly traveled across the border for work or to visit family on the other side — were tested for covid. Salinas said it was only if the symptoms persisted that patients would perhaps be evaluated for tuberculosis. This lag time allowed the illness to progress in individual patients and potentially spread in the community.

This reflects a nationwide trend. According to , U.S. tuberculosis incidence rates “decreased steadily” from 1993 to 2019. In 2020, though, there was a “sharp” decline of nearly 20% in recorded cases, which the CDC materials suggest may be due to “delayed or missed TB diagnoses or a true reduction in TB incidence related to pandemic mitigation efforts and changes in immigration and travel.” But because TB is more contagious than covid (its particles stay in the air longer), steps like masking and distancing are less effective. So, Salinas argues the former.

Convincing people of the need to test for TB was difficult even before covid, Lopez said. For starters, some health workers wrongly considered the illness a nonissue. That tuberculosis and covid share similar symptoms became another complication. When doctors and other health professionals saw those symptoms, their first concern was covid. And for a while, it was their only concern.

Other issues are diagnosis and treatment. Samples for covid rapid tests, and even the more sensitive and expensive PCR tests, can be collected with a simple nasal swab. TB screening is more invasive, done with either a skin test that requires a follow-up visit to a health professional or a blood draw that is tested in a lab. At the height of the pandemic, Lopez said, providers were so focused on getting people in and out of clinics and hospitals quickly that taking the time to conduct TB screenings wasn’t a priority.

Though TB is a curable disease, its treatment can require up to a year of prescribed antibiotics, which experts say adds to the urgency of detecting cases early on.

The Texas Department of State Health Services says on that tuberculosis rates are “higher along the Texas-Mexico border” than in the rest of the state. , chief of infectious diseases at Texas Tech University Health Sciences Center in El Paso, said that’s because “almost all cases of tuberculosis in the United States are coming from immigrants.”

, a former Texas Medical Association president who is a member of the group’s, added that many people live in Mexico but work in Texas, and vice versa, “so with that comes perhaps unclear health issues and exposure.”

There’s yet another snag. Tuberculosis, Villarreal explained, is especially hard for people’s immune system to suppress if they also have other health issues, and the border is a hot spot for diabetes and other chronic health conditions like hypertension or heart disease.

Covid, itself, is something of a comorbidity because it can make people more susceptible to tuberculosis. Some of her patients have had both illnesses, Salinas said. She suspects some who died of covid may have had tuberculosis as well, or instead.

Border areas tend to be impoverished, and “TB is a disease of the poor,” Texas Tech’s Meza said. “And who is poor in this country? The minorities, the immigrant populations, the mentally ill who live in close gatherings and shared common spaces.” Not to mention people who are uninsured and can’t afford health care.

Meza said he drives by the border often, and when he does, he sees crowds waiting on the Mexican side in Juárez, hoping to get across. If they do, he said, he hopes they get proper health screenings and care.

“To me, that’s what I’m afraid of more than covid,” Meza said. “If there is no change systematically, then that’s when things can get more complicated.”

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Alma earned her reputation as a trusted source of information through her internship as a junior community health worker. She was among 35 Fresno County students recently trained to discuss how covid vaccines help , and to encourage relatives, peers, and community members to stay up to date on their shots, including boosters.

When Alma’s internship drew to a close in October, she and seven teammates assessed their work in a capstone project. The students took pride in being able to share facts about covid vaccines. Separately, Alma persuaded her family to get vaccinated. She said her relatives, who primarily had received covid information from Spanish-language news, didn’t believe the risks until a close family friend died.

“It makes you want to learn more about it,” Alma said. “My family is all vaccinated now, but we learned the hard way.”

Community health groups in California and across the country are training teens, many of them Hispanic or Latino, and deputizing them to serve as health educators at school, on social media, and in communities where covid vaccine fears persist. According to a 2021 survey commissioned by Voto Latino and conducted by Change Research, said they didn’t trust the safety of the vaccines. The number jumped to 67% for those whose primary language at home is Spanish. The most common reasons for declining the shot included not trusting that the vaccine will be effective and not trusting the vaccine manufacturers.

And vaccine hesitancy is not prevalent only among the unvaccinated. Although of Hispanics and Latinos have received at least one dose of a covid vaccine, few report staying up to date on their shots, according to the Centers for Disease Control and Prevention. The CDC estimated of Hispanics and Latinos have received a bivalent booster, an updated shot that public health officials recommend to protect against newer variants of the virus.

Health providers and advocates believe that young people like Alma are well positioned to help get those vaccination numbers up, particularly when they help navigate the health system for their Spanish-speaking relatives.

“It makes sense we should look to our youth as covid educators for their peers and families,” said Dr. Tomás Magaña, an assistant clinical professor in the pediatrics department at the University of California-San Francisco. “And when we’re talking about the Latino community, we have to think deeply and creatively about how to reach them.”

Some training programs use peer-to-peer models on campuses, while others teach teens to fan out into their communities. , a public youth corps based in Oakland, is leveraging programs in California, New Mexico, Colorado, and Michigan to turn students into covid vaccine educators. And the in Florida, which trains high school juniors and seniors to teach freshmen about physical and emotional health, integrates covid vaccine safety into its curriculum.

In Fresno, the junior community health worker program, called , adopted the promotora model. Promotoras are non-licensed health workers in Latino communities tasked with guiding people to medical resources and promoting better lifestyle choices. that promotoras are trusted members of the community, making them uniquely positioned to provide vaccine education and outreach.

“Teenagers communicate differently, and they get a great response,” said Sandra Celedon, CEO of , one of the organizations that helped design the internship program for students 16 and older. “During outreach events, people naturally want to talk to the young person.”

The teens participating in Promotoritos are mainly Latino, immigrants without legal status, refugee students, or children of immigrants. They undergo 20 hours of training, including social media campaign strategies. For that, they earn school credit and were paid $15 an hour last year.

“Nobody ever thinks about these kids as interns,” said Celedon. “So we wanted to create an opportunity for them because we know these are the students who stand to benefit the most from a paid internship.”

Last fall, Alma, who is Latina, and three other junior community health workers distributed covid testing kits to local businesses in their neighborhood. Their first stop was Tiger Bite Bowls, an Asian fusion restaurant. The teens huddled around the restaurant’s owner, Chris Vang, and asked him if he had any questions about covid. Toward the end of their conversation, they handed him a handful of covid test kits.

“I think it’s good that they’re aware and not afraid to share their knowledge about covid,” Vang said. “I’m going to give these tests to whoever needs them — customers and employees.”

There’s another benefit of the program: exposure to careers in health care.

California faces a in the health care industry, and health professionals don’t always reflect the increasing diversity of the state’s population. Hispanics and Latinos represent 39% of California’s population, but only 6% of the state’s physician population and 8% of the state’s medical school graduates, according to a .

Alma said she joined the program in June after she saw a flyer at the school counselor’s office. She said it was her way to help prevent other families from losing a loved one.

Now, she is interested in becoming a radiologist.

“At my age,” Alma said, “this is easily the perfect way to get involved.”

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Alma se ganó su reputación como fuente de información fiable gracias a sus prácticas como trabajadora comunitaria de salud.

Fue una de los 35 estudiantes del condado de Fresno a los que se formó recientemente para explicar cómo las vacunas de covid ayudan a , y para animar a familiares, compañeros y miembros de la comunidad a estar al día con sus vacunas, incluidas las de refuerzo.

Cuando Alma terminó sus prácticas en octubre, ella y siete compañeros de equipo evaluaron su trabajo en un proyecto final. Los estudiantes estaban orgullosos de poder llevar a cabo este trabajo de divulgación sobre las vacunas.

Alma convenció a su familia para que se vacunara. Dijo que sus familiares, que habían recibido información sobre covid a través de las noticias en español, no creían en los riesgos hasta que murió un amigo cercano de la familia.

“Te dan ganas de saber más”, dijo Alma. “Ahora toda mi familia está vacunada, pero aprendimos por las malas”.

Organizaciones comunitarias de salud en California y en todo el país forman a adolescentes, muchos de ellos latinos, para que actúen como educadores de la salud en la escuela, en las redes sociales y en las comunidades donde persiste el miedo a la vacuna contra covid.

Según una encuesta de 2021 encargada por Voto Latino y realizada por Change Research, el dijeron que no confiaban en la seguridad de las vacunas. La cifra se dispara hasta el 67% en el caso de aquellos cuyo idioma principal en casa es el español. Las razones más comunes para rechazar la vacuna incluyen no confiar en su eficacia y no confiar en los fabricantes de la vacuna.

Y las dudas sobre las vacunas no solo prevalecen entre los no vacunados. Aunque de hispanos y latinos han recibido al menos una dosis de la vacuna contra covid, pocos afirman estar al día en sus vacunas, según los Centros para el Control y la Prevención de Enfermedades (CDC).

Los CDC estiman que de los latinos han recibido un refuerzo bivalente, una vacuna actualizada que los funcionarios de salud pública recomiendan para proteger contra las nuevas variantes del virus.

Proveedores y activistas de salud creen que los jóvenes, como Alma, están bien posicionados para ayudar a aumentar esas cifras de vacunación, especialmente cuando ayudan a navegar por el sistema sanitario a sus familiares hispanohablantes.

“Tiene sentido que consideremos a nuestros jóvenes como educadores en materia de vacunas ante sus compañeros y familias”, afirmó el doctor Tomás Magaña, profesor del departamento de pediatría de la Universidad de California-San Francisco. “Y cuando hablamos de la comunidad latina, tenemos que pensar con seriedad y creatividad en cómo llegar a ellos”.

Algunos programas de formación utilizan modelos para estudiantes en los campus, mientras que otros enseñan a los adolescentes a abrirse camino en sus comunidades.

, una organización de jóvenes con sede en Oakland, aprovecha programas en California, Nuevo México, Colorado y Michigan para convertir a los estudiantes en educadores sobre la vacuna contra covid.

Y el de Florida, que forma a estudiantes de primer y segundo año de secundaria para que enseñen a los de primer año sobre salud física y emocional, integra la seguridad de la vacuna contra covid en su plan de estudios.

En Fresno, el programa para jóvenes trabajadores comunitarios de la salud, llamado , adoptó el modelo promotoras.

Las promotoras son trabajadoras sanitarias, sin licencia, de las comunidades latinas encargadas de orientar a las personas hacia los recursos médicos y promover mejores opciones de estilo de vida. que las promotoras son miembros de confianza de la comunidad, lo que las sitúa en una posición privilegiada para ofrecer educación y divulgación sobre las vacunas.

“Los adolescentes se comunican de forma diferente, y obtienen una gran respuesta”, afirmó Sandra Celedon, CEO de , una de las organizaciones que ayudó a diseñar el programa de prácticas para estudiantes de 16 años o más. “Durante los eventos de divulgación, todos quieren hablar con los jóvenes”.

Los adolescentes que participan en Promotoritos son principalmente latinos, inmigrantes indocumentados, estudiantes refugiados o hijos de inmigrantes. Reciben 20 horas de formación, que incluyen estrategias de campaña en las redes sociales. Por ello, obtienen créditos escolares y el año pasado les pagaron $15 la hora.

“Nadie piensa en estos chicos como becarios”, señaló Celedon. “Así que queríamos crear una oportunidad para ellos porque sabemos que estos son los estudiantes que más se pueden beneficiar de unas prácticas remuneradas”.

El otoño pasado, Alma, que es latina, y otros tres jóvenes trabajadores comunitarios de salud distribuyeron kits de pruebas covid en negocios locales de su barrio.

Su primera parada fue Tiger Bite Bowls, un restaurante de fusión asiática. Los adolescentes hablaron con el propietario del restaurante, Chris Vang, y le preguntaron si tenía alguna duda sobre covid. Al final de la conversación, le entregaron un puñado de kits de pruebas.

“Creo que es bueno que estén concienciados y no tengan miedo de compartir sus conocimientos sobre covid”, afirmó Vang. “Voy a entregar estas pruebas a quien las necesite: clientes y empleados”.

Otro beneficio del programa: los jóvenes se familiarizan con las carreras en el campo de la salud.

California se enfrenta a una , y los profesionales de la salud no siempre reflejan la creciente diversidad de la población del estado.

Hispanos y latinos representan el 39% de la población de California, pero son solo el 6% de los médicos del estado y el 8% de los licenciados en medicina, según un informe de la .

Alma se unió al programa en junio después de ver un folleto en la oficina del consejero escolar. Dijo que era su forma de ayudar a evitar que otras familias perdieran a un ser querido.

Ahora está interesada en convertirse en radióloga.

“A mi edad”, añadió Alma, “esta es la manera perfecta de contribuir con mi comunidad”.

Esta historia fue producida por KHN, que publica , un servicio editorialmente independiente de la .

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Drug sales provide the bulk of the revenue for Genesis, a nonprofit community health center treating about 11,000 mostly low-income patients in seven clinics across South Carolina.

Those sales helped Genesis record a $19 million surplus on $52 million in revenue — a margin of 37% — in 2021, according to its audited financial statement. It was the fourth consecutive year the center’s surpluses had topped 35%, the records showed. The industry average is 5%, according to a federally funded report on health centers’ financial performance.

Genesis attributes its large margins to excellent management and says it needs the money to expand and modernize services while being less reliant on government funding. The center benefits financially from the use of a government drug discount program.

Still, Genesis’ hefty surplus stands out among nonprofit federally qualified health centers, a linchpin in the nation’s safety net for treating the poor.

The federal government pumped more than $6 billion in basic funding grants last year into around the country, which provide primary care for mostly low-income people. In 2021, the American Rescue Plan Act provided an additional $6 billion over two years for covid-19 care.

These community health centers must take all patients regardless of their ability to pay, and, in return, they receive annual government grants and higher reimbursement rates from Medicaid and Medicare than private physicians.

Yet a KHN analysis found that a handful of the centers recorded profit margins of 20% or more in at least three of the past four years. Health policy experts said the surpluses alone should not raise concerns if the health centers are planning to use the money for patients.

But they added that the high margins suggest a need for greater federal scrutiny of the industry and whether its money is being spent fast enough.

“No one is tracking where all their money is going,” said , an assistant professor at the University of Oklahoma who has studied health center finances.

The federal Health Resources and Services Administration, which regulates the centers, has limited authority under federal law over how much the centers spend on services and how they use their surpluses, said , an associate administrator.

“The expectation is they will take any profit and plow it back into the operations of the center,” Macrae said. “It’s definitely something we will look at and what they are doing with those resources,” he added about KHN’s findings.

, an accounting and health professor at Johns Hopkins University, questioned why some centers should be making profit margins of 20% or more over consecutive years.

A center with a high margin “raises questions about where did the surplus go” and its tax-exempt status, Bai said. “The centers have to provide enough benefit to deserve their public tax exemption, and what we are seeing here is a huge amount of profits,” she said.

Bai said centers must be able to answer questions about “why aren’t they doing more to help the local community by expanding their scope of service.”

Officials at the health centers defended their strong surpluses, saying the money allows them to expand services without being dependent on federal funds and helps them save for big projects, such as constructing new buildings. They pointed out that their operations are overseen by boards of directors, at least 51% of whom must be patients, ostensibly so operations meet the community’s needs.

“Health centers are expected to have operating reserves to be financially sustainable,” said Ben Money, a senior vice president at the National Association of Community Health Centers. Surpluses are necessary “as long as health centers have plans to spend the money to help patients,” he said.

Some center officials noted bottom-line profit margins can be skewed by large contributions earmarked for building projects. Grants and donations appear as revenue in the year they were given, but a project’s costs are allocated on financial statements over a longer period, often decades.

‘We Don’t Take Unnecessary Risks’

The annual federal base grant for centers makes up about 20% of their funding on average, according to HRSA. The grants have more than doubled over the past decade. These federal grants to the centers are provided on a competitive basis each year based on a complex formula that takes into account an area’s need for services and whether clinics provide care to specific populations, such as people who are homeless, agricultural workers, or residents of public housing.

The centers also receive Medicare and Medicaid reimbursements that can be as much as twice what the federal programs pay private doctors, said Jeffrey Allen, a partner with the consulting firm Forvis.

In addition, some health centers like Genesis also benefit from the 340B federal drug discount program, which allows them to buy medicines from manufacturers at deeply discounted rates. The patients’ insurers typically pay the centers a higher rate, and the clinics keep the difference. Clinics can reduce the out-of-pocket costs for patients but are not required to.

For its analysis, KHN started with research by Davlyatov that used centers’ tax filings to the IRS to identify the two dozen centers with the highest profit margins in 2019. KHN calculated bottom-line profit margin for each of the past four years (2018 through 2021) by subtracting total expenses from total revenue, which yields that year’s surplus, and then dividing that by total revenue. Money given by donors for restricted uses was excluded from revenue. After examining the centers’ finances, KHN found nine that had margins of 20% or more for at least three years.

North Mississippi Primary Health Care was one of them.

“We don’t take unnecessary risks with corporate assets,” said Christina Nunnally, chief quality officer at the center. In 2021, the center had nearly $9 million in surpluses on $36 million in revenue. More than $25 million of that revenue came from the sale of drugs.

Nunnally said the center is building a financial cushion in case the 340B program ends. Drugmakers have been seeking changes to the program.

The center recently opened a school-based health program, a dental clinic, and clinics in neighboring counties.

“There may come a day when this type of margin is not feasible anymore,” she said. If the center hits hard times, it would not want to “have to start cutting programs and people.”

In Montana, Sapphire Community Health in Hamilton, which accumulated nearly $3 million in surpluses from 2018 through 2020 and had a profit margin of more than 24% in each of those years, wants to move out of its rented quarters to a building that will cost at least $6 million to construct. “A new facility will enable us to provide services that we cannot provide due to lack of space, such as imaging, obstetrics, and dental services,” CEO Janet Woodburn said.

Outside Los Angeles, Friends of Family Health Center CEO said his high margins are the result of good management and California’s broad Medicaid coverage for low-income residents.

The center — whose profit margins topped 25% from 2018 to 2020 — opened a $1.9 million facility in Ontario last year and purchased the building that houses its main clinic, in La Habra, for $12.3 million, with plans to expand it, he said.

Bahremand added that the center also keeps administrative costs down by focusing on having more providers in relatively fewer locations.

“You shouldn’t be asking: ‘Why are we making so much money?’ You should be asking: ‘How come other clinics are not making so much money?’” Bahremand said.

Concern About Paying the Bills

In South Carolina, Genesis began as an independent clinic and was sometimes barely able to make payroll, said Tony Megna, Genesis’ CEO and general counsel. Converting to a federally qualified health center about a decade ago brought federal funding and a more solid footing. It recorded more than $65 million in surpluses from 2018 to 2021.

“Our attitude toward money is different than most because it’s so ingrained in us to be concerned about whether we are going to pay our bills,” said Katie Noyes, chief special projects officer.

The center is spending $50 million to renovate and expand its aging facilities, Megna said. In Darlington, a new $20 million building that will more than double the facility’s space is scheduled to open in 2023. And its strong bottom line helps the center pay all its workers at least $15.45 an hour, more than twice the minimum wage in the state, Megna said. Darlington County’s annual median household income is a bit over $37,000.

Megna was paid nearly $877,000 in salary and bonuses in 2021, according to Genesis’ latest IRS tax filing, an amount nearly four times the industry average.

David Corry, chairman-elect of the Genesis board of directors, said in a memo to KHN that part of that compensation made up for several years when Megna was inadvertently underpaid. “We determined early on that providing Mr. Megna an ‘average’ compensation like those of other FQHCs CEOs was not what we wanted. Mr. Megna’s extensive legal experience and education as well as his institutional and regulatory knowledge set him apart from others.”

Megna said his base salary is $503,000.

Genesis officials said the financial security afforded by the center’s surpluses has allowed them to provide extra patient services, including foot care for people with diabetes. In 2020, Genesis used $2 million to create an independent foundation to help families with food and utility bills, among other needs.

Most of Genesis’ revenue comes from the 340B program, according to its audited financial statements. Many prescriptions filled at the clinic pharmacy are for expensive specialty drugs, which treat rare or complex conditions such as cancer. Getting accredited to dispense specialty drugs was expensive, Corry said, but “paid off because it gives our patients access to extremely high-priced, and often lifesaving prescription drugs that would not otherwise be available to many of them.”

Megna, 67, a former bankruptcy lawyer, said it’s vital to keep the center financially secure to stay open for patients.

“We are very careful in how we spend our money,” Megna said.

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They converted an old farmhouse into a seven-bed medical center. They treated their first patient for a broken leg amid carpenters hammering nails. Surgeons laid their patients on a kitchen table for operations.

The hospital — then named after St. Margaret, known for her service to the poor — eventually became one of the largest in the area. Hundreds of thousands of Indiana and Illinois residents took their first, or last, breaths there.

A hundred twenty-four years later, the hospital has, in a sense, come full circle. This spring, , the nonprofit owner — still affiliated with the same Catholic order of sisters — plans to demolish most of the 226-bed Franciscan Health Hammond complex, leaving only eight beds, an emergency department, and outpatient services. The move cost 83 jobs at the hospital and 110 more at a long-term acute-care center that rented space there.

The news stung many in this Rust Belt city of nearly 80,000 people, who have watched businesses — and neighbors — flee Hammond for decades. It’s especially painful, they say, because the hospital system has dedicated more than half a billion dollars in recent years to new facilities in wealthier, less-diverse communities.

“It’s deplorable that a Catholic institution like the Franciscans would make a financially motivated decision and leave thousands of people potentially at risk,” said Mayor Thomas McDermott Jr., who complained that he was informed of the downsizing barely two hours before it was announced publicly. “I’m not trying to be alarmist, but people are gonna die because of this decision. And they know it.”

But the larger question is whether Hammond needs a hospital with hundreds of beds, given the shifts in medical practice and transportation in the 21st century. Only 50 to 60 of its beds are full on most days, said hospital CEO Patrick Maloney. Another Franciscan Alliance hospital is only 6 miles away. Much more care today is being delivered on an outpatient or virtual basis than even five years ago.

And the Hammond site has had quality concerns. It rates only one out of five stars on , the lowest possible score and worst of any of the nine rated hospitals in its county.

“Stewardship of our resources is one of the components of our Catholic mission,” Maloney stated in an email. “Key to that is efficient delivery of care.”

He noted that Franciscan is investing $45 million to transform the campus and will continue to operate a medical clinic there for uninsured or underinsured patients, as well as services like imaging, a medical lab, and prenatal care.

While rural hospital closures often get more attention, cities like Hammond have also been prone to losing medical services, as health systems adjust to changes in care, and opt to invest in places where more people have private insurance. But the shutdowns raise questions about the changing mission of nonprofit hospitals — and whom they help.

Since the 1930s, the urban hospitals most likely to close are those serving low-income, minority populations, according to research by , professor at the Boston University School of Public Health. He calls large swaths of Detroit and New York City “medical wastelands.”

When the city hospital in Hartford, Connecticut, contracted in the 1970s, it kept its emergency room running — until that got too expensive, Sager said. “I predict, within a decade, despite the best intentions of everyone involved, it will prove financially unsustainable to support an eight-bed hospital plus ER in Hammond,” he said.

Hammond’s population is down about a third from its peak in the mid-20th century. Like other former manufacturing hubs in the Midwest and Northeast, the city has been hollowed out by deindustrialization and white flight to suburban areas. It is in the part of Indiana, affectionately known as “the Region,” that’s essentially an extension of south Chicago, crisscrossed with freight train tracks, dissected by interstates, littered with factories in various states of decay.

On a recent overcast morning, Franciscan Health Hammond’s parking garage and surrounding lots were mostly empty. A sprinkling of people trickled out of the hospital. A sign advised that birthing services had moved to the suburbs.

The that covers the hospital and its surrounding neighborhood has a poverty rate of 36%, with a median household income of $30,400. Its population is 82% Black and/or Latino. The hospital treats a large share of patients on Medicaid, the government insurance program for low-income people, which typically pays health care providers a lower rate than Medicare or private insurance.

For Franciscan Alliance, the driving factors in shrinking Franciscan Health Hammond were the costs required to maintain the aging infrastructure, and less demand for care expected in that part of “the Region,” Maloney said.

He said Hammond residents are welcome at Franciscan Alliance’s hospital 6 miles away in Munster, Indiana. The organization has spent at least $133 million in recent years on that facility, located in a wealthier suburb only a few blocks from a larger, competing hospital.

But for Carlotta Blake-King, a Hammond school board trustee, that’s not close enough, especially since the area doesn’t have much mass transit. “I’m a senior citizen. I don’t like to drive,” she said. “Everybody can’t afford a car.”

Free transportation to medical appointments, though, is offered through the and .

Franciscan Alliance has replaced older hospitals in other communities, albeit a few miles from their original locations, spending $333 million on a new medical center in Crown Point, Indiana, and $243 million in Michigan City, Indiana. In 2018, however, it shuttered a century-old hospital in Chicago Heights, Illinois, a working-class Chicago suburb demographically similar to Hammond.

The missions of many nonprofit hospital chains like Franciscan Alliance have evolved. Around the turn of the 20th century, hospitals often deliberately set up shop in less-fortunate neighborhoods, with community members providing time, money, and supplies. When St. Margaret opened, for example, local farmers donated food. The Internal Revenue Service exempted so-called charity hospitals from paying taxes.

Today, “hospitals are operating as corporations, as moneymaking business entities, and their decisions are largely driven by financial concerns,” said , a professor of accounting and health policy at Johns Hopkins University. “The line between the current nonprofit hospitals and for-profit hospitals is very, very murky.”

In 2018, nonprofit hospitals provided less unreimbursed Medicaid and charity care than their for-profit counterparts, Bai’s . However, she noted, Franciscan Alliance spent more than the average nonprofit on both fronts.

Pat Vosti, a retired nurse from Hammond, worked in the cardiology unit, so she knows how time is of the essence in health care. She’s concerned about patients who have to be diverted to other hospitals. “It’s a matter of minutes, but minutes count in some instances, you know?” she said.

However, people have been bypassing the Hammond hospital for years. Along with its sister campus in Dyer, Indiana, it has only a 15% market share, according to a 2016 bond filing, compared with 45% for Franciscan’s Michigan City facility and 38% for Crown Point.

“Now, why they haven’t been using it could be a function of management choices made 15, 20 years ago: ‘Don’t build that new ER, don’t recruit those young doctors, don’t open a service for substance abuse,’” said , an adjunct professor at the Harvard T.H. Chan School of Public Health. “This is usually a gradual death. These places don’t suddenly go bad.”

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Scott trabaja en una oficina a la sombra de la fábrica de acero que empleaba a su abuelo en esta ciudad cada vez más pequeña en el área metropolitana de St. Louis. Con muchos de los trabajos del acero se ha ido parte de la estabilidad del área: de los residentes de Granite City viven en la pobreza, mucho más que el .

Luego golpeó covid-19, otro desestabilizador. Y ahi fue cuando Scott intervino: asistiendo a los que se quedaron sin trabajo, tienen covid y necesitan pagar la renta. Llevando artículos de limpieza o alimentos de un banco de alimentos local. Aconsejando sobre cómo mantener las finanzas para pagar las cuentas y no tener que cerrar negocios. Y las llamadas siguen llegando porque la gente sabe que ella entiende y ayuda.

“He tenido hambre. No he tenido auto”, dijo Scott. “He pasado por esas cosas”.

Scott es una de los más de 650 trabajadores de salud comunitarios que el Departamento de Salud Pública de Illinois contrató a través de organizaciones comunitarias locales desde marzo pasado. Esta fuerza laboral del Programa de Navegadores de Salud para Pandemias fue posible gracias a una subvención de casi $55 millones de los Centros para el Control y la Prevención de Enfermedades (CDC) a través del alivio federal aprobado por el Congreso.

El equipo ha completado al menos 45,000 solicitudes de asistencia, que les fueron remitidas a través del rastreo de contactos de casos de covid.

A medida que los trabajadores se han ganado la confianza de la comunidad, Scott dijo que han llegado nuevas solicitudes de personas que han oído hablar del programa general, en donde los navegadores hacen más que ayudar en cuestiones de salud pública.

Pero el dinero se acabará a fines de junio. Trabajadores como Scott no están seguros de su futuro y el de las personas a las que ayudan cada día. El , director ejecutivo de la Asociación Estadounidense de Salud Pública, dijo que es lo que ocurre históricamente con la financiación de salud pública. “A medida que los dólares desaparezcan, veremos a algunas personas caer al precipicio”, dijo.

El problema, como lo ve Benjamin, es la falta de una visión sistemática de la salud pública en el país. “Si hicieras esto con tu ejército, nunca podrías tener un sistema de seguridad sólido”.

Los trabajadores de salud comunitarios se posicionaron como un componente clave de la agenda de salud pública del presidente Joe Biden. Idealmente, son como el vecino en quien se puede confiar cuando se necesita ayuda. Pero ha sido difícil que estos programas reciban fondos de manera consistente.

Se suponía que cientos de millones de dólares se destinarían a construir una fuerza laboral de salud comunitaria después de que el American Rescue Plan Act se convirtiera en ley en marzo pasado, dijo Denise Smith, directora ejecutiva fundadora de la .

Pero, agregó, gran parte del dinero se gasta rápidamente en departamentos de salud o iniciativas nacionales, no en organizaciones comunitarias locales. “Para las facturas y la deuda del auto, el alquiler o los niños, eso simplemente no es sostenible”, dijo. “No podemos hacerlo gratis”.

El programa de Illinois trata de contratar trabajadores dentro de las comunidades. Dos tercios se identifican como latinos, o negros no hispanos. Alrededor del 40% estaba desempleado anteriormente, y contratarlos inyecta dinero en las comunidades a las que sirven. Cobran de $20 a $30 por hora, y casi la mitad de los empleos incluyen seguro médico o un estipendio para cubrirlo.

Tracey Smith, quien supervisa el Pandemic Health Navigator Program para el Departamento de Salud Pública de Illinois y no está relacionada con Denise Smith, considera que pagar por tales trabajadores es una necesidad, no un lujo, para ayudar a las personas a navegar el sistema de atención médica quebrado de la nación y los programas de asistencia gubernamentales inconexos.

Angelia Gower, vicepresidenta de la NAACP en Madison, Illinois, es ahora una de esas trabajadoras comunitarias de salud pagas. “Te ven semana tras semana, y mes tras mes, y todavía estás ahí, empiezan a confiar”, dijo. “Estás haciendo una conexión”.

Pero a medida que disminuyeron los casos de covid en Illinois, la cantidad de trabajadores de salud durante la pandemia se redujo en casi un tercio, a aproximadamente 450, en parte porque encontraron otras oportunidades.

Smith es optimista de que el programa obtendrá dinero para mantener a unos 300 trabajadores de salud comunitarios en el personal, y aprovechar la credibilidad que han construido en las comunidades para enfocarse en la prevención de enfermedades.

El sistema de salud estadounidense fragmentado, y sus desigualdades sistémicas, no desaparecerán con covid, dijo. Además, millones de personas están a punto de perder su cobertura de Medicaid a medida que se agoten los beneficios por la pandemia, dijo Benjamin, creando una brecha en su red de seguridad.

Parte del desafío de financiamiento a largo plazo es cuantificar lo que hacen los trabajadores como Scott en un día, especialmente si no se relaciona directamente con covid u otra enfermedad transmisible.

 ¿Cómo tabula la diferencia que se hace en la vida de un cliente cuando está asegurando camas para sus hijos, computadoras portátiles para que vayan a la escuela o aprovechando los fondos de FEMA para pagar por el funeral de un ser querido que murió por covid? ¿Cómo asigna un monto en dólares a los servicios integrales que pueden mantener a flote a una familia, especialmente cuando no hay una emergencia de salud pública?

Denise Smith teme que ocurra lo mismo que con muchas subvenciones de la Ley de Cuidado de Salud a Bajo Precio (ACA). En 2013, trabajaba como trabajadora de salud comunitaria en Connecticut, ayudando a reducir la tasa de personas sin seguro en su área en un 50%. Pero el dinero se acabó y el programa simplemente desapareció.

Mientras se esperan más fondos, Scott no puede evitar preocuparse por personas como Christina Lewis, de 40 años.

Cuando sale de la casa móvil de Lewis después de dejar una caja de alimentos, Scott le recuerda a Lewis que siga usando máscara incluso cuando otras personas ya no la usan. Lewis dijo que la ayuda de Scott ha sido invaluable. Lewis se ha quedado en casa durante la pandemia para proteger a su hija de 5 años, Briella, quien nació prematura y tiene una enfermedad pulmonar crónica. La lucha por llegar a fin de mes está lejos de terminar en medio de la creciente inflación.

Bromeando sobre el precio de la gasolina, Lewis dijo: “Ya sé, voy a tener que conseguir una bicicleta”.

En los últimos meses, Scott escuchó y consoló a Lewis mientras lloraba por el estrés de mantenerse a flote y perder familiares a causa de covid. Scott no está segura de qué pasará con todos sus clientes si su apoyo desaparece.

“¿Qué le sucede a la gente cuando todo desaparece?”, se preguntó.

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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