Kaiser Health News
Readers and Tweeters Are Horrified by Harm Tied to Dental Device
by
Fri, 31 Mar 2023 09:00:00 +0000
Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.
Teeth-Gnashing History Repeats Itself
In reading about the AGGA (Anterior Growth Guidance Appliance) dental appliance and the associated problems (“This Dental Device Was Sold to Fix Patients' Jaws. Lawsuits Claim It Wrecked Their Teeth,” March 1), I noted in your article no reference to a similar problem with the proplast-teflon product to treat TMJ, or temporomandibular joint disorder, from the 1980s and '90s, which caused equivalent damages. It amazes me that essentially the same story happened again. The proplast-teflon product even resulted in congressional-level investigations. And the product was summarily removed by FDA order throughout the United States.
Thank you for your good investigative work.
— Dr. Abbey Strauss, Boca Raton, Florida
Horrifying story. Dental device sold without undergoing FDA regulation, numerous stories of patients with wrecked jaws and teeth. https://t.co/tCqFk6PFsI via @khnews
— Joseph Ross (@jsross119) March 15, 2023
— Dr. Joseph Ross, New Haven, Connecticut
This problem seems to expand beyond the AGGA device to the Las Vegas Institute's entire methodology. The same thing was promised/done to me with braces by LVI-trained dental professionals. I was in braces for six years, and my teeth have spaces they cannot fill now — all while I'm still paying off my debt and unable to afford additional work.
— Chrystal Wilson, Roanoke, Virginia
It's just embarrassing that this happens here.https://t.co/v1kNXof5VQ
— doug hirsch (@dougjoe) February 28, 2023
— Doug Hirsch, CEO of GoodRx, Santa Monica, California
Slipping Through a Billing Loophole
I help support the type of network that this article references (“Bill of the Month: Surprise-Billing Law Loophole: When ‘Out of Network' Doesn't Quite Mean Out of Network, Feb. 28). I think it is important for KHN to educate people on narrow-network products, which was the product the Laskey family selected for their medical insurance benefits. These products have lower monthly premium costs for people who select into them, like the Laskeys, but reduce their in-network provider options, hence the term “narrow network.”
These narrow networks may carry out educational webinars, attend open-enrollment fairs, and have a website (in addition to the payer's website) so that members are educated about the narrow-network offering. With the adoption of more value-based care in the USA, narrow networks are likely to become more prevalent, and more people will need to understand the insurance products, and their networks.
— David Mayo, Denver
#CDC‘s 2016 guidelines that led to crackdown on #opioid prescribing practices now replaced with new guidelines encouraging physicians to focus on needs of individual patients. But the damage is done. https://t.co/J0eNwVkj5b #chronicpain #painmanagement #opioidcrisis #DEA #FDA
— Greg Slabodkin (@Slabodkin) March 15, 2023
— Greg Slabodkin, Niagara Falls, New York
Chronic Pain Patients' Chronic Rx Hurdles
Saw the article about how the Centers for Disease Control and Prevention guidelines the past few years have scared too many doctors until hardly any prescribe opioids anymore (“New CDC Opioid Guidelines: Too Little, Too Late for Chronic Pain Patients?” March 15).
Just wanted to chime in that I am having the exact same problem. I have chronic pain, arthritis throughout my body, a degenerative disc disorder, and even more documented medical problems. I recently broke my collarbone and was given only a two-day supply of opioid medication for it. And my pain doctor's office doesn't even prescribe me opioids.
I've also been treated horribly in the past when I was on an opioid. And if it weren't for my family doctor's understanding, I would still be living in so much pain that life seemed too hard to live with this much misery. I'm on what they call Tylenol 4, with codeine; it barely holds the pain back, but I still cannot handle cold weather (and I hate the heat) or even doing normal chores around my house without going into such a bad pain state I have to stay in bed. If I were able to get the pain medicine appropriate for my condition, I could actually enjoy things again. But because of the “opioid crisis,” that would make me an addict, by most doctor's opinions. I know the CDC didn't mean to make many chronic pain patients live in misery, but in my experience, that's exactly what has happened. And there's nothing I can do about it.
So I wanted to thank you for the article because I don't think society or the medical community truly understands what the guidelines did to people like those in your article, or like me either. Thank you so much for writing that!
— Michelle Shivpuri, Cedar Hill, Texas
Great to see other journalists finally picking this story up https://t.co/b3BN48vE8o but so many are still enthusiastically repeating myths about pain and opioids
— Maia Szalavitz (@maiasz) March 15, 2023
— Maia Szalavitz, New York City
Cost-Cutting Tools You Can Use
I am a 66-year-old female who had a colonoscopy and polyps removed at a hospital. This was my first screening of this kind, and upon completion I was billed $882 out-of-pocket. Luckily I was listening to your “Bill of the Month” coverage on South Carolina public radio. It educated me of my rights to preventive care under Obamacare. I was able to dispute the bill with success. But I must add here that my health insurance company tried to discourage me from challenging this bill. It made me feel that the bill was correct and that I should feel lucky that it was only that much. I was very disappointed, so I persisted to fill out another dispute in which I quoted KHN and threatened further action. Within a few weeks, my insurer rescinded the bill I had to pay $0. Big thanks to KHN-NPR's “Bill of the Month”!
— Angela Thomas, Myrtle Beach, South Carolina
‘The veterinary tranquilizer xylazine – the choice du jour of local drug dealers to cut fentanyl – can lead to necrotic ulcers and leaves street medics and physicians confused about how best to deal with this wave of the opioid crisis' https://t.co/pP1AQUHkmn#Xylazine
— Giuseppe Biondi-Zoccai (@gbiondizoccai) February 24, 2023
— Giuseppe Biondi-Zoccai, Rome
Warning: Painting a Graphic Picture of Drug Use
I recently came across your Kensington “tranq dope” article (“Postcard from a Philadelphia neighborhood: As Opioids Mixed With Animal Tranquilizers Arrive in Kensington, So Do Alarming Health Challenges,” Feb. 15). I have been in the health care field for 20-plus years and recently married a recovering addict, so it brought back a bad and vivid memory I'd like to share with the community of Kensington — the users, as well as the first responders, and health care providers, and wound care treatment teams who so graciously step in and up to help individuals suffering from xylazine's horrific effects.
My husband, Joshua, who became addicted to opioids after being prescribed painkillers for shoulder surgery 20 years ago, was a previous xylazine user only because it was in just about all of the supposed “heroin” bags he bought. One day he said to me, “Why does it feel like something is crawling under my skin?” After looking at his arms, with big nasty-looking sores on them, I replied, “I have no clue.” Thinking he was just “high” and making it up or just hallucinating, I went back to bed. A few hours later, he woke me saying there were worms or maggots coming out of his arms. So, again, I go into the bathroom with him to see what he was talking about, and sure enough it certainly looked exactly like what he had described. Clearly, he needed to be checked out, but being a stubborn, bullheaded man — along with being labeled, judged, and treated poorly previously when seeking medical attention — he did not seek care. A few days later, he was still pulling these things out of his arms and, finally, I persuaded him to be seen by a doctor. The entire doctor's office couldn't believe what they were looking at, so after going over everything it could have been, we learned that it was, in fact, a parasite. The doctor's best explanation was that the drug Josh had injected must have been contaminated with larvae, and it was producing parasites.
Now let's take a minute and think about this. Hmm. Horse tranquilizer, horseflies, maggots, or worms … whichever you'd like to call them. It makes sense, doesn't it? So just use caution when treating individuals and please watch for any possible parasites that may not be treated properly. My husband was given antibiotics, a steroid, and a cream to treat the problem and is doing fine now, but the critters have left nasty scars on his arms for him to have a daily reminder of, for sure.
“Tranq dope” is so hard to get off of, and the detox and withdrawal symptoms are extremely hard to handle and overcome, my husband says. Also, there's not enough information on how to treat or counteract the symptoms. After being clean for just over a year, he relapsed again and went back to the streets of Philly. He is currently incarcerated at a Montgomery County correctional facility, helping his fellow inmates become aware of how serious and dangerous xylazine really is. Our dream is to someday open a fully functional safe house and outreach program within the Philadelphia area to assist as many individuals as possible and show them a better way of life and help them start their new journey.
— Jill Romanishan, Williamsport, Pennsylvania
I don't know if anyone remembers the drug that Russians were addicted too in the 2000-2010 era. #Krokodil — highly addictive, flesh eating sores which led to amputations, most often: death. Now it's #tranq https://t.co/jCkPJd6xwg
— RiverRatDoc (@RiverRatDoc) March 13, 2023
—D.B. Pritt, Clayton, New York
Shoring Up Coverage Ahead of the Great Unwinding
Millions of Americans could lose Medicaid coverage soon (“Medicaid Health Plans Try to Protect Members — And Profits — During Unwinding,” March 9). This problem could be solved seamlessly by Congress expanding public option health insurance in all states in 2023. Do petition the White House, the entire U.S. Senate, and the entire House of Representatives to expand it in all 50 states to provide health care to millions of Americans still without health care or who are about to lose state Medicaid coverage soon.
— Piotr Sliwka, Manassas Park, Virginia
Medicaid Health Plans Try to Protect Members — And Profits — During Unwinding https://t.co/fv5GyqWXzu via @khnews // Get help from the health plan during Medicaid unwinding. they don't want to lose members or continuity of care either.
— Marcella Maguire, Ph.D. (@Cella65) March 9, 2023
— Marcella Maguire, Philadelphia
Title: Readers and Tweeters Are Horrified by Harm Tied to Dental Device
Sourced From: khn.org/news/article/letters-to-editor-readers-and-tweeters-agga-dental-device-chronic-pain-cdc/
Published Date: Fri, 31 Mar 2023 09:00:00 +0000
Kaiser Health News
Tire Toxicity Faces Fresh Scrutiny After Salmon Die-Offs
Jim Robbins
Wed, 24 Apr 2024 09:00:00 +0000
For decades, concerns about automobile pollution have focused on what comes out of the tailpipe. Now, researchers and regulators say, we need to pay more attention to toxic emissions from tires as vehicles roll down the road.
At the top of the list of worries is a chemical called 6PPD, which is added to rubber tires to help them last longer. When tires wear on pavement, 6PPD is released. It reacts with ozone to become a different chemical, 6PPD-q, which can be extremely toxic — so much so that it has been linked to repeated fish kills in Washington state.
The trouble with tires doesn't stop there. Tires are made primarily of natural rubber and synthetic rubber, but they contain hundreds of other ingredients, often including steel and heavy metals such as copper, lead, cadmium, and zinc.
As car tires wear, the rubber disappears in particles, both bits that can be seen with the naked eye and microparticles. Testing by a British company, Emissions Analytics, found that a car's tires emit 1 trillion ultrafine particles per kilometer driven — from 5 to 9 pounds of rubber per internal combustion car per year.
And what's in those particles is a mystery, because tire ingredients are proprietary.
“You've got a chemical cocktail in these tires that no one really understands and is kept highly confidential by the tire manufacturers,” said Nick Molden, CEO of Emissions Analytics. “We struggle to think of another consumer product that is so prevalent in the world and used by virtually everyone, where there is so little known of what is in them.”
Regulators have only begun to address the toxic tire problem, though there has been some action on 6PPD.
The chemical was identified by a team of researchers, led by scientists at Washington State University and the University of Washington, who were trying to determine why coho salmon returning to Seattle-area creeks to spawn were dying in large numbers.
Working for the Washington Stormwater Center, the scientists tested some 2,000 substances to determine which one was causing the die-offs, and in 2020 they announced they'd found the culprit: 6PPD.
The Yurok Tribe in Northern California, along with two other West Coast Native American tribes, have petitioned the Environmental Protection Agency to prohibit the chemical. The EPA said it is considering new rules governing the chemical. “We could not sit idle while 6PPD kills the fish that sustain us,” said Joseph L. James, chairman of the Yurok Tribe, in a statement. “This lethal toxin has no place in any salmon-bearing watershed.”
California has begun taking steps to regulate the chemical, last year classifying tires containing it as a “priority product,” which requires manufacturers to search for and test substitutes.
“6PPD plays a crucial role in the safety of tires on California's roads and, currently, there are no widely available safer alternatives,” said Karl Palmer, a deputy director at the state's Department of Toxic Substances Control. “For this reason, our framework is ideally suited for identifying alternatives to 6PPD that ensure the continued safety of tires on California's roads while protecting California's fish populations and the communities that rely on them.”
The U.S. Tire Manufacturers Association says it has mobilized a consortium of 16 tire manufacturers to carry out an analysis of alternatives. Anne Forristall Luke, USTMA president and CEO, said it “will yield the most effective and exhaustive review possible of whether a safer alternative to 6PPD in tires currently exists.”
Molden, however, said there is a catch. “If they don't investigate, they aren't allowed to sell in the state of California,” he said. “If they investigate and don't find an alternative, they can go on selling. They don't have to find a substitute. And today there is no alternative to 6PPD.”
California is also studying a request by the California Stormwater Quality Association to classify tires containing zinc, a heavy metal, as a priority product, requiring manufacturers to search for an alternative. Zinc is used in the vulcanization process to increase the strength of the rubber.
When it comes to tire particles, though, there hasn't been any action, even as the problem worsens with the proliferation of electric cars. Because of their quicker acceleration and greater torque, electric vehicles wear out tires faster and emit an estimated 20% more tire particles than the average gas-powered car.
A recent study in Southern California found tire and brake emissions in Anaheim accounted for 30% of PM2.5, a small-particulate air pollutant, while exhaust emissions accounted for 19%. Tests by Emissions Analytics have found that tires produce up to 2,000 times as much particle pollution by mass as tailpipes.
These particles end up in water and air and are often ingested. Ultrafine particles, even smaller than PM2.5, are also emitted by tires and can be inhaled and travel directly to the brain. New research suggests tire microparticles should be classified as a pollutant of “high concern.”
In a report issued last year, researchers at Imperial College London said the particles could affect the heart, lungs, and reproductive organs and cause cancer.
People who live or work along roadways, often low-income, are exposed to more of the toxic substances.
Tires are also a major source of microplastics. More than three-quarters of microplastics entering the ocean come from the synthetic rubber in tires, according to a report from the Pew Charitable Trusts and the British company Systemiq.
And there are still a great many unknowns in tire emissions, which can be especially complex to analyze because heat and pressure can transform tire ingredients into other compounds.
One outstanding research question is whether 6PPD-q affects people, and what health problems, if any, it could cause. A recent study published in Environmental Science & Technology Letters found high levels of the chemical in urine samples from a region of South China, with levels highest in pregnant women.
The discovery of 6PPD-q, Molden said, has sparked fresh interest in the health and environmental impacts of tires, and he expects an abundance of new research in the coming years. “The jigsaw pieces are coming together,” he said. “But it's a thousand-piece jigsaw, not a 200-piece jigsaw.”
This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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By: Jim Robbins
Title: Tire Toxicity Faces Fresh Scrutiny After Salmon Die-Offs
Sourced From: kffhealthnews.org/news/article/tire-toxicity-salmon-die-offs-research-6ppd/
Published Date: Wed, 24 Apr 2024 09:00:00 +0000
Did you miss our previous article…
https://www.biloxinewsevents.com/ftc-chief-says-tech-advancements-risk-health-care-price-fixing/
Kaiser Health News
FTC Chief Says Tech Advancements Risk Health Care Price Fixing
Julie Rovner, KFF Health News and David Hilzenrath
Tue, 23 Apr 2024 13:13:59 +0000
New technologies are making it easier for companies to fix prices and discriminate against individual consumers, the Biden administration's top consumer watchdog said Tuesday.
Algorithms make it possible for companies to fix prices without explicitly coordinating with one another, posing a new test for regulators policing the market, said Lina Khan, chair of the Federal Trade Commission, during a media event hosted by KFF.
“I think we could be entering a somewhat novel era of pricing,” Khan told reporters.
Khan is regarded as one of the most aggressive antitrust regulators in recent U.S. history, and she has paid particular attention to the harm that technological advances can pose to consumers. Antitrust regulators at the FTC and the Justice Department set a record for merger challenges in the fiscal year that ended Sept. 30, 2022, according to Bloomberg News.
Last year, the FTC successfully blocked biotech company Illumina's over $7 billion acquisition of cancer-screening company Grail. The FTC, Justice Department, and Health and Human Services Department launched a website on April 18, healthycompetition.gov, to make it easier for people to report suspected anticompetitive behavior in the health care industry.
The American Hospital Association, the industry's largest trade group, has often criticized the Biden administration's approach to antitrust enforcement. In comments in September on proposed guidance the FTC and Justice Department published for companies, the AHA said that “the guidelines reflect a fundamental hostility to mergers.”
Price fixing removes competition from the market and generally makes goods and services more expensive. The agency has argued in court filings that price fixing “is still illegal even if you are achieving it through an algorithm,” Khan said. “There's no kind of algorithmic exemption to the antitrust laws.”
By simply using the same algorithms to set prices, companies can effectively charge the same “even if they're not, you know, getting in a back room and kind of shaking hands and setting a price,” Khan said, using the example of residential property managers.
Khan said the commission is also scrutinizing the use of artificial intelligence and algorithms to set prices for individual consumers “based on all of this particular behavioral data about you: the websites you visited, you know, who you had lunch with, where you live.”
And as health care companies change the way they structure their businesses to maximize profits, the FTC is changing the way it analyzes behavior that could hurt consumers, Khan said.
Hiring people who can “help us look under the hood” of some inscrutable algorithms was a priority, Khan said. She said it's already paid off in the form of legal actions “that are only possible because we had technologists on the team helping us figure out what are these algorithms doing.”
Traditionally, the FTC has policed health care by challenging local or regional hospital mergers that have the potential to reduce competition and raise prices. But consolidation in health care has evolved, Khan said.
Mergers of systems that don't overlap geographically are increasing, she said. In addition, hospitals now often buy doctor practices, while pharmacy benefit managers start their own insurance companies or mail-order pharmacies — or vice versa — pursuing “vertical integration” that can hurt consumers, she said.
The FTC is hearing increasing complaints “about how these firms are using their monopoly power” and “exercising it in ways that's resulting in higher prices for patients, less service, as well as worse conditions for health care workers,” Khan said.
Policing Noncompetes
Khan said she was surprised at how many health care workers responded to the commission's recent proposal to ban “noncompete” clauses — agreements that can prevent employees from moving to new jobs. The FTC issued its final rule banning the practice on Tuesday. She said the ban was aimed at low-wage industries like fast food but that many of the comments in favor of the FTC's plan came from health professions.
Health workers say noncompete agreements are “both personally devastating and also impeded patient care,” Khan said.
In some cases, doctors wrote that their patients “got really upset because they wanted to stick with me, but my hospital was saying I couldn't,” Khan said. Some doctors ended up commuting long distances to prevent the rest of their families from having to move after they changed jobs, she said.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
USE OUR CONTENT
This story can be republished for free (details).
——————————
By: Julie Rovner, KFF Health News and David Hilzenrath
Title: FTC Chief Says Tech Advancements Risk Health Care Price Fixing
Sourced From: kffhealthnews.org/news/article/ftc-lina-khan-price-fixing-noncompete-mergers/
Published Date: Tue, 23 Apr 2024 13:13:59 +0000
Did you miss our previous article…
https://www.biloxinewsevents.com/unsheltered-people-are-losing-medicaid-in-redetermination-mix-ups/
Kaiser Health News
Unsheltered People Are Losing Medicaid in Redetermination Mix-Ups
Aaron Bolton, MTPR
Tue, 23 Apr 2024 09:00:00 +0000
KALISPELL, Mont. — On a cold February morning at the Flathead Warming Center, Tashya Evans waited for help with her Medicaid application as others at the shelter got ready for the day in this northwestern Montana city.
Evans said she lost Medicaid coverage in September because she hadn't received paperwork after moving from Great Falls, Montana. She has had to forgo the blood pressure medication she can no longer pay for since losing coverage. She has also had to put off needed dental work.
“The teeth broke off. My gums hurt. There's some times where I'm not feeling good, I don't want to eat,” she said.
Evans is one of about 130,000 Montanans who have lost Medicaid coverage as the state reevaluates everyone's eligibility following a pause in disenrollments during the covid-19 pandemic. About two-thirds of those who were kicked off state Medicaid rolls lost coverage for technical reasons, such as incorrectly filling out paperwork. That's one of the highest procedural disenrollment rates in the nation, according to a KFF analysis.
Even unsheltered people like Evans are losing their coverage, despite state officials saying they would automatically renew people who should still qualify by using Social Security and disability data.
As other guests filtered out of the shelter that February morning, Evans sat down in a spare office with an application counselor from Greater Valley Health Clinic, which serves much of the homeless population here, and recounted her struggle to reenroll.
She said that she had asked for help at the state public assistance office, but that the staff didn't have time to answer her questions about which forms she needed to fill out or to walk her through the paperwork. She tried the state's help line, but couldn't get through.
“You just get to the point where you're like, ‘I'm frustrated right now. I just have other things that are more important, and let's not deal with it,'” she said.
Evans has a job and spends her free time finding a place to sleep since she doesn't have housing. Waiting on the phone most of the day isn't feasible.
There's no public data on how many unhoused people in Montana or nationwide have lost Medicaid, but homeless service providers and experts say it's a big problem.
Those assisting unsheltered people who have lost coverage say they spend much of their time helping people contact the Montana Medicaid office. Sorting through paperwork mistakes is also a headache, said Crystal Baker, a case manager at HRDC, a homeless shelter in Bozeman.
“We're getting mail that's like, ‘Oh, this needs to be turned in by this date,' and that's already two weeks past. So, now we have to start the process all over again,” she said. “Now, they have to wait two to three months without insurance.”
Montana health officials told NPR and KFF Health News in a statement that they provided training to help homeless service agencies prepare their clients for redetermination.
Federal health officials have warned Montana and some other conservative states against disenrolling high rates of people for technicalities, also known as procedural disenrollment. They also warned states about unreasonable barriers to accessing help, such as long hold times on help lines. The Centers for Medicare & Medicaid Services said if states don't reduce the rate of procedural disenrollments, the agency could force them to halt their redetermination process altogether. So far, CMS hasn't taken that step.
Charlie Brereton, the director of the Montana health department, resisted calls from Democratic state lawmakers to pause the redetermination process. Redetermination ended in January, four months ahead of the federal deadline.
“I'm confident in our redetermination process,” Brereton told lawmakers in December. “I do believe that many of the Medicaid members who've been disenrolled were disenrolled correctly.
Health industry observers say that both liberal-leaning and conservative-leaning states are kicking homeless people off their rolls and that the redetermination process has been chaotic everywhere. Because of the barriers that unsheltered people face, it's easy for them to fall through the cracks.
Margot Kushel, a physician and a homeless researcher at the University of California-San Francisco, said it may not seem like a big deal to fill out paperwork. But, she said, “put yourself in the position of an elder experiencing homelessness,” especially those without access to a computer, phone, or car.
If they still qualify, people can usually get their Medicaid coverage renewed — eventually — and it may reimburse patients retroactively for care received while they were unenrolled.
Kushel said being without Medicaid for any period can be particularly dangerous for people who are homeless. This population tends to have high rates of chronic health conditions.
“Being out of your asthma medicine for three days can be life-threatening. If you have high blood pressure and you suddenly stop your medicine, your blood pressure shoots up, and your risk of having a heart attack goes way up,” she said.
When people don't understand why they're losing coverage or how to get it back, that erodes their trust in the medical system, Kushel said.
Evans, the homeless woman, was able to get help with her application and is likely to regain coverage.
Agencies that serve unhoused people said it could take years to get everyone who lost coverage back on Medicaid. They worry that those who go without coverage will resort to using the emergency room rather than managing their health conditions proactively.
Baker, the case manager at the Bozeman shelter, set up several callbacks from the state Medicaid office for one client. The state needed to interview him to make sure he still qualified, but the state never called.
“He waited all day long. By the fifth time, it was so stressful for him, he just gave up,” she said.
That client ended up leaving the Bozeman area before Baker could convince him it was worth trying to regain Medicaid.
Baker worries his poor health will catch up with him before he decides to try again.
This article is from a partnership that includes MTPR, NPR, and KFF Health News.
——————————
By: Aaron Bolton, MTPR
Title: Unsheltered People Are Losing Medicaid in Redetermination Mix-Ups
Sourced From: kffhealthnews.org/news/article/unsheltered-people-losing-medicaid-redetermination-paperwork/
Published Date: Tue, 23 Apr 2024 09:00:00 +0000
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