Kaiser Health News

Clues From Bird Flu’s Ground Zero on Dairy Farms in the Texas Panhandle

Published

3 weeks ago

May 23, 2024

Amy Maxmen
Thu, 23 May 2024 09:00:00 +0000

In early February, dairy farmers in the Texas Panhandle began to notice sick cattle. The buzz soon reached Darren Turley, executive director of the Texas Association of Dairymen: “They said there is something moving from herd to herd.”

Nearly 60 days passed before veterinarians identified the culprit: a highly pathogenic strain of the bird flu virus, H5N1. Had it been detected sooner, the outbreak might have been swiftly contained. Now it has spread to at least eight other states, and it will be hard to eliminate.

At the moment, the bird flu hasn't adapted to spread from person to person through the air like the seasonal flu. That's what it would take to give liftoff to another pandemic. This lucky fact could change, however, as the virus mutates within each cow it infects. Those mutations are random, but more cows provide more chances of stumbling on ones that pose a grave risk to humans.

Why did it take so long to recognize the virus on high-tech farms in the world's richest country? Because even though H5N1 has circulated for nearly three decades, its arrival in dairy cattle was most unexpected. “People tend to think that an outbreak starts at Monday at 9 a.m. with a sign saying, ‘Outbreak has started,'” said Jeremy Farrar, chief scientist at the World Health Organization. “It's rarely like that.”

By investigating the origins of outbreaks, researchers garner clues about how they start and spread. That information can curb the toll of an epidemic and, ideally, stop the next one. On-the-ground observations and genomic analyses point to Texas as ground zero for this outbreak in cattle. To backtrack events in Texas, KFF Health News spoke with more than a dozen people, including veterinarians, farmers, and state officials.

An early indication that something had gone awry on farms in northwestern Texas came from devices hitched to collars on dairy cows. Turley describes them as “an advanced fitness tracker.” They collect a stream of data, such as a cow's temperature, its milk quality, and the progress of its digestion — or, rather, rumination — within its four-chambered stomach.

What farmers saw when they downloaded the data in February stopped them in their tracks. One moment a cow seemed perfectly fine, and then four hours later, rumination had halted. “Shortly after the stomach stops, you'd see a huge falloff in milk,” Turley said. “That is not normal.”

Tests for contagious diseases known to whip through herds came up negative. Some farmers wondered if the illness was related to ash from wildfires devastating land to the east.

In hindsight, Turley wished he had made more of the migrating geese that congregate in the panhandle each winter and spring. Geese and other waterfowl have carried H5N1 around the globe. They withstand enormous loads of the virus without getting sick, passing it on to local species, like blackbirds, cowbirds, and grackles, that mix with migrating flocks.

But with so many other issues facing dairy farmers, geese didn't register. “One thing you learn in agriculture is that Mother Nature is unpredictable and can be devastating,” Turley said. “Just when you think you have figured it out, Mother Nature tells you you do not.”

Cat Clues

One dairy tried to wall itself off, careful not to share equipment with or employ the same workers as other farms, Turley recalled. Its cattle still became ill. Turley noted that the farm was downwind of another with an outbreak, “so you almost think it has to have an airborne factor.”

On March 7, Turley called the Texas Animal Health Commission. They convened a One Health group with experts in animal health, human health, and agriculture to ponder what they called the “mystery syndrome.” State veterinarians probed cow tissue for parasites, examined the animals' blood, and tested for viruses and bacteria. But nothing explained the sickness.

They didn't probe for H5N1. While it has jumped into mammals dozens of times, it rarely has spread between species. Most cases have been in carnivores, which likely ate infected birds. Cows are mainly vegetarian.

“If someone told me about a milk drop in cows, I wouldn't think to test for H5N1 because, no, cattle don't get that,” said Thomas Peacock, a virologist at the Pirbright Institute of England who studies avian influenza.

Postmortem tests of grackles, blackbirds, and other birds found dead on dairy farms detected H5N1, but that didn't turn the tide. “We didn't think much of it since we have seen H5N1-positive birds everywhere in the country,” said Amy Swinford, director of the Texas A&M Veterinary Medical Diagnostic Laboratory.

In the meantime, rumors swirled about a rash of illness among workers at dairy farms in the panhandle. It was flu season, however, and hospitals weren't reporting anything out of the ordinary.

Bethany Boggess Alcauter, director of research at the National Center for Farmworker Health, has worked in the panhandle and suspected farmworkers were unlikely to see a doctor even if they needed one. Clinics are far from where they live, she said, and many don't speak English or Spanish — for instance, they may speak Indigenous languages such as Mixtec, which is common in parts of Mexico. The cost of medical care is another deterrent, along with losing pay by missing work — or losing their jobs — if they don't show up. “Even when medical care is there,” she said, “it's a challenge.”

What finally tipped off veterinarians? A few farm cats died suddenly and tested positive for H5N1. Swinford's group — collaborating with veterinary labs at Iowa State and Cornell universities — searched for the virus in samples drawn from sick cows.

“On a Friday night at 9 p.m., March 22, I got a call from Iowa State,” Swinford said. Researchers had discovered antibodies against H5N1 in a slice of a mammary gland. By Monday, her team and Cornell researchers identified genetic fragments of the virus. They alerted authorities. With that, the U.S. Department of Agriculture announced that H5N1 had hit dairy cattle.

Recalling rumors of sick farmworkers, Texas health officials asked farmers, veterinarians, and local health departments to encourage testing. About 20 people with coughs, aches, irritated eyes, or other flu-like symptoms stepped forward to be swabbed. Those samples were shipped to the Centers for Disease Control and Prevention. All but one was negative for H5N1. On April 1, the CDC announced this year's first case: a farmworker with an inflamed eye that cleared up within days.

Thirteen dairy farms in the panhandle had been affected, said Brian Bohl, director of field operations at the Texas Animal Health Commission. Farmers report that outbreaks among the herds last 30 to 45 days and most cows return to milking at their usual pace.

The observation hints that herds gain immunity, if temporarily. Indeed, early evidence shows that H5N1 triggers a protective antibody response in cattle, said Marie Culhane, a professor of veterinary population medicine at the University of Minnesota. Nonetheless, she and others remain uneasy because no one knows how the virus spreads, or what risk it poses to people working with cattle.

Although most cows recover, farmers said the outbreaks have disrupted their careful timing around when cattle milk, breed, and birth calves.

Farmers want answers that would come with further research, but the spirit of collaboration that existed in the first months of the Texas outbreak has fractured. Federal restrictions have triggered a backlash from farmers who find them unduly punishing, given that pasteurized milk and cooked beef from dairy cattle appear to pose no risk to consumers.

The rules, such as prohibiting infected cattle from interstate travel for 30 days, pose a problem for farmers who move pregnant cattle to farms that specialize in calving, to graze in states with gentler winters, and to return home for milking. “When the federal order came out, some producers said, ‘I'm going to quit testing,'” Bohl said.

In May, the USDA offered aid, such as up to $10,000 to test and treat infected cattle. “The financial incentives will help,” Turley said. But how much remains to be seen.

Federal authorities have pressed states to extract more intel from farms and farmworkers. Several veterinarians warn such pressure could fracture their relationships with farmers, stifling lines of communication.

Having fought epidemics around the world, Farrar cited examples of when strong-arm surveillance pushed outbreaks underground. During an early 2000s bird flu outbreak in Vietnam, farmers circumvented regulations by moving poultry at night, bribing inspection workers, and selling their goods through back channels. “Learning what drivers and fears exist among people is crucial,” Farrar said. “But we always seem to realize that at a later date.”

A powerful driver in the U.S.: Milk is a $60 billion industry. Public health is also bound to bump up against politics in Texas, a state so aggrieved by pandemic restrictions that lawmakers passed a bill last year barring health officials from recommending covid-19 vaccines.

Texas Agriculture Commissioner Sid Miller said that when he heard that federal agents with the CDC and USDA were considering visits to farms — including those where farmers reported the cattle had recovered — he advised against it. “Send federal agents to dairy that's not sick?” he said. “That doesn't pass the smell test.”

From Texas to the Nation

Peacock said genomic analyses of H5N1 viruses point to Texas as ground zero for the cattle epidemic, emerging late last year.

“All of these little jigsaw puzzle pieces corroborate undetected circulation in Texas for some time,” said Peacock, an author on one report about the outbreak.

Evidence suggests that either a single cow was infected by viruses shed from birds — perhaps those geese, grackles, or blackbirds, he said. Or the virus spilled over from birds into cattle several times, with only a fraction of those moving from cow to cow.

Sometime in March, viruses appear to have hitched a ride to other states as cows were moved between farms. The limited genomic data available links the outbreak in Texas directly to others in New Mexico, Kansas, Ohio, North Carolina, and South Dakota. However, the routes are imprecise because the USDA hasn't attached dates and locations to data it releases.

Researchers don't want to be caught off guard again by the shape-shifting H5N1 virus, and that will require keeping tabs on humans. Most, if not all, of about 900 people diagnosed with H5N1 infections worldwide since 2003 acquired it from animals, rather than from humans, Farrar said. About half of those people died.

Occasional tests of sick farmworkers aren't sufficient, he said. Ideally, a system is set up to encourage farmworkers, their communities, and health care workers to be tested whenever the virus hits farms nearby.

“Health care worker infections are always a sign of human-to-human transmission,” Farrar said. “That's the approach you want to take — I am not saying it's easy.”

——————————
By: Amy Maxmen
Title: Clues From Bird Flu's Ground Zero on Dairy Farms in the Texas Panhandle
Sourced From: kffhealthnews.org/news/article/bird-flu-ground-zero-texas-dairy-farms-whodunit-h5n1/
Published Date: Thu, 23 May 2024 09:00:00 +0000

Post Views: 72

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Indiana Weighs Hospital Monopoly as Officials Elsewhere Scrutinize Similar Deals

Published

2 days ago

June 14, 2024

Staff Editor

Samantha Liss
Fri, 14 Jun 2024 09:00:00 +0000

TERRE HAUTE, Ind. — Locals in this city of 58,000 are used to having to wait at railroad crossings for one of the dozens of daily cargo trains to pass through.

But a proposed merger between the two hospitals on either side of the city could exacerbate the problem in emergencies if the hospitals shut down some services, such as trauma care, at one site, which the proposal cites as a possibility. Tom High, fire chief of a nearby township, said some first responders would be forced to transport critical patients farther, risking longer delays, if they become what locals call “railroaded” by a passing train.

That's just one of the fears in this community as Indiana officials review whether to allow Union Hospital, licensed as a 341-bed facility, to purchase the county's only other acute care hospital, the 278-bed Terre Haute Regional Hospital. The proposed deal also raises concerns about reduced tax revenue, worsening care, and higher prices.

Within the next few months, the Indiana Department of Health must find “clear evidence” that the proposed merger would improve health outcomes, access, and the quality of care. Those benefits must “outweigh any potential disadvantages.”

As the nation's health care industry has become more concentrated amid a steady clip of mergers in recent decades, it's common for one large system to dominate a market. In this case, the deal would be Indiana's first merger under the COPA law, short for Certificate of Public Advantage, that the state enacted in 2021. Such laws allow deals that the Federal Trade Commission otherwise considers illegal because they reduce competition and often create monopolies. To mitigate the negative effects of a monopoly, the merged hospitals typically agree to conditions imposed by state regulators.

Union Hospital leaders said it's time to move “beyond competition” for the sake of the region, which has struggled to keep jobs and raise life expectancy rates. Hospital spokesperson Neil Garrison said the merger would ultimately improve care, increase access, and cut costs. Leaders of Regional Hospital, which is owned by for-profit chain HCA Healthcare, did not respond to questions about the proposal.

One unusual implication arises, though: If the merger is approved, the surrounding county would lose tax revenue from one of its larger businesses. Union Hospital, which as a nonprofit is exempt from paying taxes, would be acquiring tax-paying Terre Haute Regional, which paid roughly $508,000 in county taxes for 2023, said Vigo County Auditor Jim Bramble. That's the equivalent of the starting salaries of about nine sheriff's deputies, per the county's $83 million 2024 budget.

Garrison said the hospital system is aware of the tax implications for the county and is “exploring opportunities” to address it.

Meanwhile, Roland Kohr, formerly a pathologist at Regional and a county coroner, frets about erasing competition that forced the hospitals to add services or match the other. “The push to introduce new technologies, to recruit more physicians, that may not happen,” he said.

The FTC has urged states to avoid COPAs, pointing to research that found they “have resulted in significant price increases and contributed to declines in quality of care.” The fallout of similar mergers has triggered federal sanctions in North Carolina and pushback from locals and legislators in Tennessee.

“A merged hospital system that faces little remaining competition after the merger usually has little incentive to follow through with its promises because patients have no other choice,” wrote Chris Garmon, a University of Missouri-Kansas City economist who has studied COPA mergers, in a warning to Indiana health officials about the proposed merger.

Indiana already has among the highest hospital prices in the country, according to a study by the Rand Corp. research organization. The Indiana Legislature spent the past year trying to rein in prices. Gloria Sachdev, CEO of Indianapolis-based Employers' Forum of Indiana, which pushed for those pricing limits on behalf of frustrated business leaders, is worried a Union-Regional merger would undo those gains and raise prices further.

Indiana's COPA restricts how much the hospital could increase charges, Garrison said.

Elsewhere, the largest COPA-created hospital system in the country, Ballad Health, has reported that the time patients spend in its ERs in Virginia and Tennessee before being hospitalized has more than tripled, reaching nearly 11 hours, in the six years since that monopoly of 20 hospitals formed. Still, Tennessee has awarded Ballad top marks even when certain quality metrics, including its ER speed, fall below established benchmarks.

Ballad Health spokesperson Molly Luton said the system's performance has improved since those statistics were gathered.

Last fall, some Tennesseans unsuccessfully urged a county board to call on the state to better regulate the hospital system. This spring, state lawmakers refused to hear testimony from residents who drove five hours to Nashville to testify for a bill that sought to limit future COPA mergers in the state — which ultimately didn't make it to a full vote.

Problems have also occurred when a COPA — and its oversight — are removed, leaving the merged hospital system as an “unregulated monopoly.” After North Carolina repealed its COPA in 2015, a subsidiary of HCA Healthcare bought Mission Health, a COPA-created monopoly in Asheville, for $1.5 billion in 2019. The monopoly in Asheville remained but none of the COPA's conditions applied to the new owner.

Last year, government inspectors found “deficiencies” at Mission Health that contributed to four patient deaths and posed an “immediate jeopardy” to patients' health and safety, according to the 384-page federal inspection report. North Carolina Attorney General Joshua Stein sued HCA's subsidiary last year, alleging the ER was “significantly degraded,” and that the company failed to maintain certain critical services, including oncology care, a violation of a purchase agreement Stein's office negotiated with it because the company acquired a nonprofit.

HCA said it promptly addressed the issues and denied Stein's allegations in its legal response to the ongoing lawsuit, arguing it has expanded services since its purchase. HCA also argued that the agreement is silent about maintaining the quality of care.

Back in Indiana, Union Hospital laid the groundwork for its merger more than three years ago when its leaders provided the language for COPA legislation to then-state Sen. Jon Ford, a Republican in Terre Haute, believing he would be “the best champion for this proposal,” according to legislative testimony from Taylor Hollenbeck, an RJL Solutions consultant on the merger. Ford, listed on the legislature's site as the bill's co-author, did not respond to requests for comment.

Union CEO Steve Holman testified in the bill's hearings that the county's public health rankings — with an average life expectancy ranking 68th out of 92 counties in the state — should be a “call to action” to do something “big and bold.”

Terre Haute Mayor Brandon Sakbun agrees the merger could help what he called the county's “abysmal” public health statistics. Last year, he was elected the city's youngest mayor at age 27 on a promise to “turn Terre Haute around.” The region's workforce has steadily declined and local leaders have pinned their hopes on a new casino and a manufacturer of battery parts for electric vehicles to reverse this trend.

Sakbun's father is an OB-GYN at Union, but the mayor said that doesn't color his opinion and that he supports the hospital merger despite the loss of the tax base. He believes it will help recruit medical and other professionals to an area that has struggled to attract top talent.

“Do I believe that this is the one that bucks the research?” Sakbun said. “I truthfully do.”

KFF Health News correspondent Brett Kelman contributed to this article.

——————————
By: Samantha Liss
Title: Indiana Weighs Hospital Monopoly as Officials Elsewhere Scrutinize Similar Deals
Sourced From: kffhealthnews.org/news/article/indiana-copa-hospital-monopoly-scrutiny/
Published Date: Fri, 14 Jun 2024 09:00:00 +0000

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Kaiser Health News

California Lawmakers Preserve Aid to Older, Disabled Immigrants

Published

2 days ago

June 14, 2024

Staff Editor

Vanessa G. Sánchez
Fri, 14 Jun 2024 09:00:00 +0000

California lawmakers on Thursday passed a 2024-25 budget that rejected Gov. Gavin Newsom's proposal to cut in-home supportive services for low-income older, blind, and disabled immigrants lacking legal residency. However, the Democratic governor has not said whether he'll use his line-item veto authority to help close the state's $45 billion deficit.

The legislature, controlled by Democrats, passed a $211 billion general fund spending plan for the fiscal year starting July 1 by drawing more from the state's rainy-day fund and reducing corporate tax deductions to prevent cuts to health and social services.

“Our legislative budget plan achieves those goals with targeted, carefully calibrated investments in safety-net programs that protect our most vulnerable,” said Assembly member Jesse Gabriel, chair of the Assembly's budget committee, following voting in Sacramento.

Newsom and lawmakers are expected to continue talks.

“What was approved today represents a two-house agreement between the Senate and the Assembly – not an agreement with the governor,” said state Department of Finance spokesperson H.D. Palmer. “We've made good progress, but there's still more work to do.”

Newsom had proposed eliminating the new in-home benefit for qualified immigrants to save nearly $95 million in the next fiscal year, with no plans to bring it back. Lawmakers not only rejected Newsom's cut to the in-home services program; they also refused the governor's proposal to slash $300 million a year from public health agencies. However, they accepted delaying food assistance to low-income older immigrants without legal residency.

The In-Home Supportive Services program helps low-income older, blind, and disabled individuals receive care in their homes, which helps keep them out of more costly nursing and residential facilities. The program works by paying $16 to $21 an hour to caregivers, many of them family members.

Advocates applauded lawmakers for rejecting the cut. They had urged the governor to adopt the legislature's budget, arguing the state could end up paying more in the long run as Medi-Cal recipients tap nursing services. The state has estimated the annual per-person cost of nursing homes is $124,189, compared with the roughly $28,000 average cost for people without legal residency in the in-home services program.

“These individuals would need to essentially go into costly hospital or nursing care,” said Ronald Coleman Baeza, managing policy director at the California Pan-Ethnic Health Network. “It's not only cruel for undocumented immigrants, but it doesn't make sense as a fiscal decision either.”

The governor has said he's trying to maintain fiscal discipline while preserving Medi-Cal benefits for immigrants. California was the first state to expand Medicaid eligibility to all qualified immigrants regardless of legal status, phasing it in over several years: children in 2016, adults ages 19-26 in 2020, people 50 and older in 2022, and all remaining adults this year.

“It's a core of I think who we are as a state, and we should be as a nation,” Newsom said in May.

As part of the Medi-Cal expansion, the state authorized nearly 3,000 older, blind, and disabled immigrants without legal residency to access paramedical services and daily care, including meal preparation, bathing, feeding, and transportation to medical appointments. Advocates estimate 17,000 immigrants qualify.

“Fixing California's deficit means making tough choices, so the Assembly came to these negotiations focused on preserving programs that matter most to Californians,” said Assembly Speaker Robert Rivas, a Central Coast Democrat, in an earlier statement.

Lawmakers did agree to Newsom's proposal to delay around $165 a month in food assistance to low-income immigrants without legal residency ages 55 and older. Lawmakers had approved the benefit two years ago, but the governor proposed delaying it by two fiscal years to 2027.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

——————————
By: Vanessa G. Sánchez
Title: California Lawmakers Preserve Aid to Older, Disabled Immigrants
Sourced From: kffhealthnews.org/news/article/california-lawmakers-aid-immigrants-in-home-services-budget-newsom/
Published Date: Fri, 14 Jun 2024 09:00:00 +0000

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Kaiser Health News

KFF Health News’ ‘What the Health?’: SCOTUS Rejects Abortion Pill Challenge — For Now

Published

3 days ago

June 13, 2024

Staff Editor

Thu, 13 Jun 2024 18:50:00 +0000

The Host

Julie Rovner
KFF Health News

@jrovner

Read Julie's stories.

Julie Rovner is chief Washington correspondent and host of KFF Health News' weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

A unanimous Supreme Court turned back a challenge to the FDA's approval and rules for the abortion pill mifepristone, finding that the anti-abortion doctor group that sued lacked standing to do so. But abortion foes have other ways they intend to curtail availability of the pill, which is commonly used in medication abortions, which now make up nearly two-thirds of abortions in the U.S.

Meanwhile, the Biden administration is proposing regulations that would bar credit agencies from including medical debt on individual credit reports. And former President Donald Trump, signaling that drug prices remain a potent campaign issue, attempts to take credit for the $35-a-month cap on insulin for Medicare beneficiaries — which was backed and signed into law by Biden.

This week's panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Rachana Pradhan of KFF Health News, and Emmarie Huetteman of KFF Health News.

Panelists

Anna Edney
Bloomberg

@annaedney

Read Anna's stories.

Emmarie Huetteman
KFF Health News

@emmarieDC

Read Emmarie's stories.

Rachana Pradhan
KFF Health News

@rachanadpradhan

Read Rachana's stories.

Among the takeaways from this week's episode:

All nine Supreme Court justices on June 13 rejected a challenge to the abortion pill mifepristone, ruling the plaintiffs did not have standing to sue. But that may not be the last word: The decision leaves open the possibility that different plaintiffs — including three states already part of the case — could raise a similar challenge in the future, and that the court could then vote to block access to the pill.
As the presidential race heats up, President Joe Biden and former President Donald Trump are angling for health care voters. The Biden administration this week proposed eliminating all medical debt from Americans' credit scores, which would expand on the previous, voluntary move by the major credit agencies to erase from credit reports medical bills under $500. Meanwhile, Trump continues to court vaccine skeptics and wrongly claimed credit for Medicare's $35 monthly cap on insulin — enacted under a law backed and signed by Biden.
Problems are compounding at the pharmacy counter. Pharmacists and drugmakers are reporting the highest numbers of drug shortages in more than 20 years. And independent pharmacists in particular say they are struggling to keep drugs on the shelves, pointing to a recent Biden administration policy change that reduces costs for seniors — but also cash flow for pharmacies.
And the Southern Baptist Convention, the nation's largest branch of Protestantism, voted this week to restrict the use of in vitro fertilization. As evidenced by recent flip-flopping stances on abortion, Republican candidates are feeling pressed to satisfy a wide range of perspectives within even their own party.

Also this week, Rovner interviews KFF president and CEO Drew Altman about KFF's new “Health Policy 101” primer. You can learn more about it here.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: HuffPost's “How America's Mental Health Crisis Became This Family's Worst Nightmare,” by Jonathan Cohn.

Anna Edney: Stat News' “Four Tops Singer's Lawsuit Says He Visited ER for Chest Pain, Ended Up in Straitjacket,” by Tara Bannow.

Rachana Pradhan: The New York Times' “Abortion Groups Say Tech Companies Suppress Posts and Accounts,” by Emily Schmall and Sapna Maheshwari.

Emmarie Huetteman: CBS News' “As FDA Urges Crackdown on Bird Flu in Raw Milk, Some States Say Their Hands Are Tied,” by Alexander Tin.

Also mentioned on this week's podcast:

Bloomberg News' “Dozens of CVS Generic Drug Recalls Expose Link to Tainted Factories,” by Anna Edney and Peter Robison.
KFF Health News' “Biden Plan To Save Medicare Patients Money on Drugs Risks Empty Shelves, Pharmacists Say,” by Susan Jaffe.
KFF Health News' “More States Legalize Sales of Unpasteurized Milk, Despite Public Health Warnings,” by Tony Leys.

Credits

Francis Ying
Audio producer

Emmarie Huetteman
Editor

To hear all our podcasts, click here.

And subscribe to KFF Health News' “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

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Title: KFF Health News' ‘What the Health?': SCOTUS Rejects Abortion Pill Challenge — For Now
Sourced From: kffhealthnews.org/news/podcast/what-the-health-351-supreme-court-abortion-pill-mifepristone-june-13-2024/
Published Date: Thu, 13 Jun 2024 18:50:00 +0000

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