But because he was uninsured at the time, the surgery at a Reno, Nevada, hospital led to years of anguish. He said he owes the hospital more than $20,000 for the procedure and still gets calls from collection agencies.

“It can cause a lot of anxiety,” Rice said. “I can’t give you what I don’t have.”

Rice, 62, was born and has spent his life in Nevada. He said he fell through a gap in the tribal health care system because he lives 1,500 miles from the Prairie Band Potawatomi Nation home area in eastern Kansas, where he’s an enrolled member.

He receives primary care at the Reno-Sparks Indian Colony tribal health clinic in Nevada, but structural barriers in the federal Indian Health Service left him without coverage for specialty care outside of the clinic. Rice might have been eligible for specialty services referred by his tribe’s health system in Kansas, but he lives too far from the tribe’s delivery area to utilize the tribal health program that helps pay for services outside of the IHS.

“I shouldn’t need to move to Kansas City to be fully covered,” Rice said.

A new tribal sponsorship program rolled out last year in Nevada is aimed at getting tribal citizens like Rice covered and protecting them from incurring debt for uninsured care. It allows tribes to buy health insurance through the state’s Affordable Care Act marketplace for people living in their service area, including Native Americans from other tribes.

Tribal leaders and Nevada officials say the sponsorship model increases access to coverage and care for tribal citizens and their families by allowing them to seek medical care outside the tribal health care system.

A few dozen tribes have moved to set up the insurance programs since the ACA authorized them more than a decade ago.

“It’s not widespread,” said Yvonne Myers, an ACA and Medicaid consultant for Citizen Potawatomi Nation Health Services in Oklahoma.

Native American adults are enrolled in Medicaid at higher rates than their white counterparts and have long faced worse health outcomes, higher incidences of chronic disease, and shorter life expectancy. Many rely on the IHS, a division within the Department of Health and Human Services responsible for providing care to Native Americans, but the agency is chronically underfunded.

In Nevada, tribes can sponsor their community members’ health coverage through aggregated billing, a method for paying the premiums for multiple individuals in a single monthly payment to the insurer. Another part of the program includes collaboration between Nevada Health Link, the state health insurance marketplace, and tribes to certify staffers at tribal health clinics so they can enroll community members in health plans. Program officials also said they are committed to providing further education to tribes about the accommodations available to them under the ACA.

Health agencies in Washington state and Nevada have helped set up tribal sponsorship programs. Independently, tribes in Alaska, Wisconsin, Idaho, Michigan, Montana, and South Dakota have rolled out individual programs, as well.

It’s already making a difference for Native American patients in Nevada, said Angie Wilson, tribal health director for the Reno-Sparks Indian Colony and an enrolled member of the Pit River Tribe in California. Wilson said patients have shown up at her office in tears because they couldn’t afford services they needed outside of the tribal clinic and were not eligible for those services to be covered by the IHS Purchased/Referred Care program.

The Reno-Sparks Indian Colony, with more than 1,330 members in 2023, is one of two tribes that participate in Nevada’s tribal sponsorship program and aggregated billing. Russell Cook, executive director of Nevada Health Link, said he expects more tribes to come aboard as the agency works to build community trust in tribes often wary of government and corporate entities.

The Fort McDermitt Paiute and Shoshone Tribe, with a reservation that spans Nevada’s northwestern border, was the first tribe to pilot the program. There are about 125 households on the reservation.

As of December, 30 tribal members had been enrolled into qualified health plans through Nevada Health Link as part of the tribal sponsorship program, according to state officials, and more than 700 of those enrolled through the state marketplace self-reported American Indian and/or Alaska Native status for last year.

Through sponsorship, tribes may use their federal health care funding to pay the premium costs for each participating person. That, combined with cost-sharing protections in the ACA for American Indian and Alaska Natives enrolled in marketplace health plans, means beneficiaries face very low to no costs to receive care outside of tribal clinics. The American Rescue Plan also expanded eligibility for premium tax credits, making purchasing a health plan more affordable.

Because sponsorship in some tribes isn’t limited to enrolled tribal citizens, it can help the whole community, said Jim Roberts, senior executive liaison for intergovernmental affairs with the Alaska Native Tribal Health Consortium and an enrolled member of the Hopi Tribe in Arizona.

Since Alaska first allowed sponsorship in 2013, Roberts said, it has not only increased the access to care for Native Americans but also significantly lowered the costs of care, “which is equally as important, if not for some tribes more important.”

In Washington state, where sponsorship in ACA plans began in 2014, 12 of 29 tribes participate.

Cook said the state exchange is seeing interest in the part of the sponsorship program that trains staff at tribal clinics to become certified exchange representatives, a role similar to that of a navigator who helps inform people about health coverage options.

He said the agency is working on a marketing campaign to spread awareness among Native Americans in the state about the sponsorship program. It will include translating resource guides and other materials from the agency into Native languages spoken in the state, such as Northern and Southern Paiute, Washoe, and Western Shoshone.

Cook said he’s surprised more states haven’t taken the initiative to create sponsorship programs in collaboration with tribes.

Nevada Health Link patterned its approach by looking at Washington state’s program, Cook said. Since launching its own program, the Nevada agency has been approached by officials in California who are exploring the option.

But leaders like Wilson are concerned that under the Trump administration the enhanced tax credits for ACA marketplace enrollees implemented during the pandemic will end. The credits are set to expire at the end of this year if Congress doesn’t act to extend them. Without the credits, nearly all people enrolled through the marketplace will see steep increases in their premium payments next year.

If tribal citizens or other community members become ineligible for the premium tax credits, that could jeopardize the tribe’s financial ability to continue sponsoring health plans, Roberts said.

“Whatever side of the fence people fall on, it does not take away that there’s a federal trust responsibility by the United States of America to its First Nations people,” Wilson said.

Wilson, who has been an advocate for sponsorship since the ACA was approved in 2010 and led the effort to establish the program in Nevada, said she is happy with the tribal sponsorship program but wishes it would have happened sooner.

“We’ve lost so much in Indian Country over time,” she said. “How many more Indian people could have gotten access to care? How much more of a difference could that have made in sustaining health care for tribes?”

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That increasing diversity is part of a wider trend. While rural America remains largely White and predominantly English-speaking, its White population decreased by about 2 million from 2010 to 2020, an analysis by the Carsey School of Public Policy at the University of New Hampshire found. The percentage of people who are members of a racial or ethnic minority living in rural areas increased from 20 percent to 24 percent, with the largest share Hispanic.

Language access is protected federally, and 11 states plus D.C. have created broad policies for their residents. More states have laws targeting specific sectors, such as education or health care.

At the height of the coronavirus pandemic, state and local governments lacking strong language-access systems struggled to communicate vital public health information to diverse communities. An analysis of covid information posted on health department websites of the 10 most populous U.S. cities found it was not fully provided in Spanish.

Despite the growing need caused by limited English proficiency in rural areas, state lawmakers in Nevada left out smaller counties from a recently enacted statewide language-access law. More state and local governments have enacted similar measures in the past few years, but they’re concentrated in urban or suburban jurisdictions.

Implementing the laws is a challenge, researchers say, as standards can vary across state agencies and localities, making it difficult to ensure high-quality assistance for speakers of various languages. Not providing language access to people who need it is not only a violation of civil rights protected by Title VI of the Civil Rights Act, but it also can create public health and safety concerns, said Jake Hofstetter, a policy analyst for the Migration Policy Institute, a think tank focused on immigration policy and research.

Democratic state Sen. Edgar Flores, who represents part of Clark County, Nevada, and co-sponsored the state’s most recent language-access law, approved in 2023, said lawmakers faced pushback from state agencies. He said officials cited limited staffing and funding.

“I think, unfortunately, our rural jurisdictions are already incredibly limited with resources and, at the time of this request, there was a concern that they were not in a position to meet the requirements,” Flores said.

But as the number of state and local language-access policies increases, Hofstetter said he expects rural areas will be included. And as the Nevada Legislature convenes again in February, Flores said he’s certain there will be at least one language-access bill to consider.

“We have folks from all walks of life who have now made Nevada their home,” Flores said. “We have an obligation to them.”

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Mendoza trabaja en Elko, Nevada, una región remota en el noreste del estado. Su labor se ha vuelto cada vez más importante a medida que la población latina de la ciudad ha crecido a aproximadamente el 26%. El porcentaje de personas de 5 años o más que hablan un idioma distinto al inglés en casa aumentó al 18% en 2022, y el español es el idioma hablado en casi el 15% de los hogares.

A pesar de la creciente demanda para que los gobiernos rurales locales se comuniquen con los residentes en idiomas distintos al inglés, los legisladores estatales en Nevada excluyeron a los condados más pequeños de una ley estatal de acceso lingüístico que se promulgó recientemente. Más gobiernos estatales y locales han implementado medidas similares en los últimos años, pero están concentradas en su mayoría en jurisdicciones urbanas o suburbanas.

Aunque la América rural es en su mayoría blanca no hispana y angloparlante, se ha vuelto rápidamente más diversa.

Sin embargo, implementar leyes estatales y locales de acceso lingüístico es un desafío, según investigadores, dado que los estándares pueden variar entre agencias estatales y localidades, lo que dificulta garantizar asistencia de alta calidad a los que hablan idiomas diferentes al inglés.

No proporcionar acceso lingüístico a quienes lo necesitan no solo constituye una violación de los derechos civiles protegidos por el Título VI de la Ley de Derechos Civiles, sino que también puede generar preocupaciones de salud y seguridad pública, dijo Jake Hofstetter, analista de políticas del Migration Policy Institute, un grupo de investigación enfocado en política migratoria.

Aunque el acceso lingüístico es una protección federal, 11 estados y Washington, D.C., han creado políticas amplias dirigidas a sus poblaciones. Algunos estados tienen leyes específicas para sectores como la educación o la atención médica. Otras leyes de acceso lingüístico se han establecido en ciudades como Austin, en Texas; Philadelphia, en Pennsylvania; y Portland, en Maine.

En el apogeo de la pandemia de covid-19, los gobiernos estatales y locales que no tenían sistemas sólidos de acceso lingüístico tuvieron dificultades para comunicar información pública vital a comunidades diversas. Un análisis de la información sobre covid publicada en los sitios web de los departamentos de salud de las 10 ciudades más pobladas del país encontró que no se proporcionaba completamente en español.

La población blanca no hispana en las áreas rurales del país disminuyó en aproximadamente 2 millones entre 2010 y 2020, según un análisis de la Escuela de Políticas Públicas Carsey de la Universidad de New Hampshire. El porcentaje de personas pertenecientes a minorías raciales o étnicas en áreas rurales aumentó del 20% en 2010 al 24% en 2020, siendo los hispanos el grupo más grande.

En 2021, 25 millones de personas de 5 años o más en Estados Unidos tenían un dominio limitado del inglés, de los cuales casi dos tercios eran hispanos, según KFF. Nevada es uno de los nueve estados donde al menos el 10% de la población tiene un dominio limitado del inglés.

Según una encuesta de 2023 realizada por KFF y Los Angeles Times, alrededor del 31% de las personas con dominio limitado del inglés enfrentaron barreras lingüísticas al intentar acceder a servicios de salud.

Una cuarta parte tuvo dificultades para solicitar ayuda del gobierno para alimentos, vivienda o cobertura médica. Además, los inmigrantes que no hablan bien inglés tuvieron el doble de probabilidades de no tener seguro médico en comparación con aquellos que dominan el idioma, y presentaron peores resultados de salud.

Desde que terminó la emergencia por la pandemia, Hofstetter ha observado un número significativo de políticas estatales que abordan el acceso lingüístico, pero no muchas políticas locales enfocadas en áreas rurales.

El experto señaló que la ley más reciente de Nevada sobre acceso lingüístico, aprobada en 2023, es única porque identifica específicamente y requiere que los condados más poblados del estado —Clark y Washoe— creen e implementen planes de acceso lingüístico. Otra ley aprobada ese mismo año destinó $25 millones a las agencias para implementar dichos planes.

El senador estatal demócrata Edgar Flores, quien representa una parte del condado de Clark y fue coautor de la ley más reciente sobre idiomas, indicó que los legisladores han enfrentado resistencia de las agencias estatales en varios intentos por fortalecer los requisitos para proporcionar información y documentos en otros idiomas. Según Flores, los funcionarios citan recursos y personal limitados.

“Creo que, desafortunadamente, nuestras jurisdicciones rurales ya están increíblemente limitadas en recursos y, en el momento de esta solicitud, había preocupación de que no estuvieran en condiciones de cumplir con los requisitos”, dijo Flores. “Esa es la realidad”.

Flores indicó que, aunque algunas agencias y jurisdicciones habían creado planes de acceso lingüístico en años anteriores, los legisladores descubrieron que no siempre se implementaban ni se hacían cumplir. Por esta razón, decidieron centrarse primero en los dos condados más grandes del estado mientras trabajan para expandir las políticas a “todos los códigos postales y todas las agencias”.

“Tenemos personas de todas partes que ahora han hecho de Nevada su hogar”, dijo Flores. “Tenemos una obligación con ellos”.

Las personas que viven en áreas rurales pueden beneficiarse de una red de recursos de agencias estatales que prestan servicios en sus condados o de programas locales que deben abordar el acceso lingüístico debido al financiamiento federal.

Pero Hofstetter señaló que existen brechas en el marco de protecciones federales, estatales y locales a nivel nacional.

El grado en que los gobiernos locales ofrecen comunicaciones en idiomas distintos al inglés varía por varias razones, incluida la aplicación de las protecciones de derechos civiles. Esa aplicación depende de quejas de derechos civiles, que a menudo deben ser presentadas por residentes que pueden no conocer sus derechos relacionados con el acceso lingüístico, dijo Hofstetter.

Los miembros de la comunidad también pueden enfrentar resistencia de los líderes locales a la expansión del acceso a servicios e información en otros idiomas.

En 2018, Mendoza apoyó la idea de ofrecer boletas en inglés y español en el condado de Elko. Los comisionados del condado, tres de los cuales aún están en la junta, votaron unánimemente para recomendar al secretario del condado retrasar la oferta de boletas bilingües tanto como fuera posible después de cuestionar los datos demográficos del censo, y alegar que no tenían fondos para traducir las boletas.

Tener acceso a boletas en su idioma preferido ayuda a los votantes a comprender mejor las iniciativas que los afectan, muchas de las cuales están relacionadas con la salud, como una pregunta en la boleta del 5 de noviembre que pedía a los votantes opinar sobre si consagrar el derecho al aborto en la constitución estatal. La medida fue aprobada con el 64% de los votantes a favor y necesita ser aprobada nuevamente en 2026 para implementarse.

La Legislatura de Nevada se reunirá nuevamente en febrero, y Flores dijo estar seguro de que habrá al menos un proyecto de ley sobre acceso lingüístico. Hofstetter anticipa más normas estatales y locales sobre el tema en los próximos años.

“Imagino que eso incluirá algunas áreas rurales”, concluyó.

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Mendoza works in Elko, Nevada, situated in a remote region in the state’s northeastern corner. Her work has become increasingly important as the town’s Hispanic or Latino population has grown to about 26%. The share of people age 5 or older who speak a language other than English at home increased to 18% as of 2022, while Spanish is the language spoken in nearly 15% of households.

Despite rising demand for local rural governments to communicate with residents in languages other than English, state lawmakers in Nevada left out smaller counties from a recently enacted statewide language-access law. More state and local governments have enacted similar measures during the past few years, but they’re mostly concentrated in urban or suburban jurisdictions.

Rural America is largely white and predominantly English-speaking but has rapidly grown more diverse. Implementing state and local language-access laws, however, is a challenge, researchers say, given standards can vary across state agencies and localities, making it difficult to ensure high-quality assistance is provided to speakers of various non-English languages. Not providing language access to people who need it is not only a violation of civil rights protected by Title VI of the Civil Rights Act, but it also can create public health and safety concerns, said Jake Hofstetter, a policy analyst for the Migration Policy Institute, a think tank focused on immigration policy and research.

While language access is a federal protection, 11 states and Washington, D.C., have created broad policies targeted to their populations. And some states have laws targeting specific sectors, such as education or health care. Other language-access laws have taken root in such municipalities as Austin, Texas; Philadelphia; and Portland, Maine.

At the height of the covid-19 pandemic, state and local governments lacking strong language-access systems struggled to communicate vital public health information to diverse communities. An analysis of covid information posted on health department websites of the 10 most populous U.S. cities found it was not fully provided in Spanish.

The number of white residents in rural parts of the nation decreased by about 2 million from 2010 to 2020, according to an analysis by the Carsey School of Public Policy at the University of New Hampshire. And the percentage of people who are members of a racial or ethnic minority living in rural areas increased from 20% in 2010 to 24% in 2020, with the largest share being Hispanic.

As of 2021, 25 million people age 5 or older in the U.S. had limited English proficiency, of whom nearly two-thirds were Hispanic, according to KFF, a health information nonprofit that includes KFF Health News. Nevada is one of nine states where at least 10% of people have limited English proficiency.

According to a 2023 KFF-Los Angeles Times survey of immigrants, about 31% with limited English proficiency said they faced language barriers when trying to access health care. A quarter said they struggled to apply for government financial help with food, housing, or health coverage. And immigrants limited in their ability to speak English were twice as likely to be uninsured as immigrants who were proficient in English, and they had worse health outcomes.

Since the pandemic emergency ended, Hofstetter has seen a significant number of state policies addressing language access, he said, but he doesn’t see many local policies that focus on the issue in rural areas.

Hofstetter said Nevada’s most recent law on language access, approved in 2023, is unique in that it specifically identifies and requires the state’s most populous counties — Clark and Washoe — to create and implement language-access plans. A separate bill, also approved last year, appropriated $25 million to agencies for implementing language access plans.

Democratic state Sen. Edgar Flores, who represents part of Clark County and was a cosponsor on the most recent language-access law, said lawmakers have faced pushback from state agencies for various attempts at strengthening requirements to provide information and documents in languages other than English. He said officials cite limited staffing and funding.

“I think, unfortunately, our rural jurisdictions are already incredibly limited with resources and, at the time of this request, there was a concern that they were not in a position to meet the requirements,” Flores said. “That’s the bottom line.”

He said that while some agencies and jurisdictions had created language-access plans in past years, legislators found they were not always implemented and enforced. For this reason, Flores said, lawmakers decided it would be better to focus on the state’s two largest counties first while they work toward expanding policies to “every ZIP code, every agency.”

“We have folks from all walks of life who have now made Nevada their home,” Flores said. “We have an obligation to them.”

People living in rural areas may still benefit from a patchwork of resources through state agencies that provide services in their counties or local programs that are required to address language access because of federal funding.

But gaps in the framework of federal, state, and local protections exist nationwide, Hofstetter said.

The degree to which local governments offer communications in languages other than English varies for several reasons, including enforcement of civil rights protections. That enforcement relies on civil rights complaints, which often must be filed by residents who may not know their rights related to language access, Hofstetter said.

Community members may also face resistance from local leaders on expanding access to services and information in other languages. In 2018, Mendoza supported offering ballots in Elko County in Spanish as well as English. County commissioners, three of whom are still on the board, unanimously voted to recommend the county clerk delay offering bilingual ballots as long as possible after questioning census demographic data and stating they didn’t have funding to translate the ballots.

Having access to ballots in their preferred language helps voters better understand initiatives affecting them, many of which are health-related, such as a Nov. 5 ballot question that asked voters to weigh in on whether to enshrine a right to abortion within the state’s constitution. The measure passed with 64% of voters in favor and needs to be approved once more in 2026 to be implemented.

The Nevada Legislature convenes again in February, and Flores said he’s certain there will be at least one language-access bill. Hofstetter said he anticipates more state and local policies addressing the issue within the next few years.

“I would imagine that that’s going to include some rural areas,” he said.

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According to the South Dakota Department of Health, 649 cases of syphilis have been documented this year. Of those, 546 were diagnosed among Native Americans, who make up only 9 percent of the state’s population.

“It’s completely preventable and curable, so something has gone horribly wrong that this has occurred,” said Meghan Curry O’Connell, the chief public health officer for the Great Plains Tribal Leaders’ Health Board and a citizen of the Cherokee Nation.

This year, the tribal leaders’ health board asked the U.S. Department of Health and Human Services to declare the outbreak a public health emergency, which could ease access to other resources that tribal leaders asked for, including public health workers, data, national stockpile supplies and funding.

According to the Great Plains Tribal Epidemiology Center, syphilis rates among Native Americans in its region, which covers Iowa, Nebraska, North Dakota and South Dakota, soared by 1,865 percent from 2020 to 2022 — more than 10 times the increase nationwide during the same period. The epidemiology center also found that 1 in 40 Native American babies born in the region in 2022 had a potentially life-threatening syphilis infection.

O’Connell said HHS officials’ response to the Great Plains Tribal Leaders’ Health Board fell short of fulfilling its requests. More recently, the National Indian Health Board also sent a letter to the agency urging it to declare a public health emergency for all tribes in the United States.

Months later, no public health emergency has been declared, and tribal and health leaders are still responding to the outbreak with limited resources.

HHS officials pointed to their work in forming a task force and hosting workshops to guide tribes’ response to the outbreak. But tribal leaders insist they need greater federal investment.

“We know how to address this, but we do need extra support and resources in order to do it,” O’Connell said.

Still, some health officials serving Native American communities say they’re seeing improvement. Natalie Holt, a physician and the chief medical officer for the Great Plains Area Indian Health Service, one of 12 regional divisions of the federal agency responsible for providing health care to Native Americans, said new cases have been declining.

Indian Health Service facilities in the region have averaged more than 1,300 syphilis tests monthly, she said, and cases are down from 93 in January to 31 in October.

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Holt works in Aberdeen, a city of about 28,000 surrounded by a sea of prairie, as a physician and the chief medical officer for the Great Plains Area Indian Health Service, one of 12 regional divisions of the federal agency responsible for providing health care to Native Americans and Alaska Natives in the U.S.

The response to this public health issue, she said, is not so different from the approach with the coronavirus pandemic — federal, state, local, and tribal groups need to “divide and conquer” as they work to test and treat residents. But they are responding to this crisis with fewer resources because federal officials haven’t declared it a public health emergency.

The public pleas for testing are part of health officials’ efforts to halt the outbreak that has disproportionately hurt Native Americans in the Great Plains and Southwest. According to the Great Plains Tribal Epidemiology Center, syphilis rates among Native Americans in its region soared by 1,865% from 2020 to 2022 — over 10 times the 154% increase seen nationally during the same period. The epidemiology center’s region spans Iowa, Nebraska, North Dakota, and South Dakota. The center also found that 1 in 40 Native American and Alaska Native babies born in the region in 2022 had a syphilis infection.

The rise in infections accelerated in 2021, pinching public health leaders still reeling from the coronavirus pandemic.

Three years later, the outbreak continues — the number of new infections so far this year is 10 times the full 12-month totals recorded in some years before the upsurge. And tribal health leaders say their calls for federal officials to declare a public health emergency have gone unheeded.

Pleas for help from local and regional tribal health leaders like Meghan Curry O’Connell, the chief public health officer for the Great Plains Tribal Leaders’ Health Board and a citizen of the Cherokee Nation, preceded a September letter from the National Indian Health Board, a Washington, D.C.-based nonprofit that advocates for health care for U.S. tribes, to publicly urge the Department of Health and Human Services to declare a public health emergency. Tribal leaders said they need federal resources including public health workers, access to data and national stockpile supplies, and funding.

According to data from the South Dakota Department of Health, 577 cases of syphilis have been documented this year in the state. Of those, 430 were among Native American people — making up 75% of the state’s syphilis cases, whereas the group accounts for just 9% of the population.

The numbers can be hard to process, O’Connell said.

“It’s completely preventable and curable, so something has gone horribly wrong that this has occurred,” she said.

The Great Plains Tribal Leaders’ Health Board first called on HHS to declare a public health emergency in February. O’Connell said the federal agency sent a letter in response outlining some resources and training it has steered toward the outbreak, but it stopped short of declaring an emergency or providing the substantial resources the board requested. The board’s now months-old plea for resources was like the recent one from the National Indian Health Board.

“We know how to address this, but we do need extra support and resources in order to do it,” she said.

Syphilis is a sexually transmitted infection that can result in life-threatening damage to the heart, brain, and other organs if left untreated. Women infected while pregnant can pass the disease to their babies. Those infections in newborns, called congenital syphilis, kill dozens of babies each year and can lead to devastating health effects in others.

Holt said the Indian Health Service facilities she oversees have averaged more than 1,300 tests for syphilis monthly. She said a recent decline in new cases detected each month — down from 92 in January to 29 in September — may be a sign that things are improving. But a lot of damage has been done during the past few years.

Cases of congenital syphilis across the country have more than tripled in recent years, according to the Centers for Disease Control and Prevention. In 2022, 3,700 cases were reported — the most in a single year since 1994.

The highest rate of reported primary and secondary syphilis cases in 2022 was among non-Hispanic American Indian or Alaska Native people, with 67 cases per 100,000, according to CDC data.

O’Connell and other tribal leaders said they don’t have the resources needed to keep pace with the outbreak.

Chief William Smith, vice president of Alaska’s Valdez Native Tribe and chairperson of the National Indian Health Board, told HHS in the organization’s letter that tribal health systems need greater federal investment so the system can better respond to public health threats.

Rafael Benavides, HHS’ deputy assistant secretary for public affairs, said the agency has received the letter sent in early September and will respond directly to the authors.

“HHS is committed to addressing the urgent syphilis crisis in American Indian and Alaska Native communities and supporting tribal leaders’ efforts to mobilize and raise awareness to address this important public health crisis,” he said.

Federal officials from the health department and the CDC have formed task forces and hosted workshops for tribes on how to address the outbreak. But tribal leaders insist a public health emergency declaration is needed more than anything else.

Holt said that while new cases seem to be declining, officials continue to fight further spread with what resources they have. But obstacles remain, such as convincing people without symptoms to get tested for syphilis. To make this easier, appointments are not required. When people pick up medications at a pharmacy, they receive flyers about syphilis and information about where and when to get tested.

Despite this “full court press” approach, Holt said, officials know there are people who do not seek health care often and may fall through the cracks.

O’Connell said the ongoing outbreak is a perfect example of why staffing, funding, data access, and other resources need to be in place before an emergency develops, allowing public health agencies to respond immediately.

“Our requests have been specific to this outbreak, but really, they’re needed as a foundation for whatever comes next,” she said. “Because something will come next.”

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But public health leaders quickly identified a familiar boom-and-bust funding cycle as they warned about an incoming fiscal cliff once the federal grants sunset. Now, more than a year since the federal Department of Health and Human Services declared the end of the coronavirus emergency, states — such as Montana, California and Washington — face tough decisions about laying off workers and limiting public health services.

In California, Democratic Gov. Gavin Newsom proposed cutting the state’s public health funding by $300 million. And the Department of Health in Washington state slashed more than 350 positions at the end of last year and more than 200 this year.

Public health experts warn that losing staff who perform functions like disease investigation, immunization, family planning, restaurant inspection and more could send communities into crisis.

“You cannot hire the firefighters when the house is already burning,” said Brian Castrucci, president and CEO of the de Beaumont Foundation, an organization that advocates for public health policy.

In late September, HHS Secretary Xavier Becerra declared a public health emergency for states affected by Hurricane Helene, allowing state and local health authorities in Florida, Georgia, North Carolina, South Carolina and Tennessee to more easily access federal resources. Last week, ahead of Hurricane Milton’s landfall in Florida, Becerra declared another public health emergency to aid the state’s response.

If states don’t have robust public health resources ready when disasters like this hit their communities, it can have devastating effects.

Local health department staffing grew by about 19 percent from 2019 to 2022, according to a report from the National Association of County and City Health Officials that examined 2,512 of the nation’s roughly 3,300 local departments. The same report found that half of those departments’ revenue in 2022 came from federal sources.

But in some places, the pandemic cash did little more than keep small health departments afloat. The Central Montana Health District, a public health agency serving five rural counties, received enough money to retain a staff member to help handle testing, contact tracing and rolling out the coronavirus vaccines. It wasn’t enough to hire extra workers, but it allowed officials to fill a position left empty when a staffer left the department, said Susan Woods, the district’s public health director.

Now, five full-time employees work for the health district — enough to scrape by, Woods said.

“Any kind of crisis, any kind of, God forbid, another pandemic, would probably send us crashing,” she said.

Adriane Casalotti, chief of government and public affairs for the national health officials’ group, said she expects layoffs and health department budget cuts to intensify. Those cuts come as health officials work to address issues that took a back seat in the pandemic, such as increases in rates of sexually transmitted infections, suicide and substance misuse.

And rural health departments deserve more attention, Casalotti said, as they are likely to be the most vulnerable and face compounding factors such as hospital closures and the loss of services including maternity and other women’s care.

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Congress allotted more than $800 billion to support states’ covid responses, fueling a surge in the public health workforce nationwide.

Local health department staffing grew by about 19% from 2019 to 2022, according to a report from the National Association of County and City Health Officials that studied 2,512 of the nation’s roughly 3,300 local departments. That same report explained that half of their revenue in 2022 came from federal sources.

But those jobs, and the safety net they provide for the people in the communities served, are vulnerable as the money dries up, worrying public health leaders — particularly in sparsely populated, rural areas, which already faced long-standing health disparities and meager resources.

Officials in such states as Montana, California, Washington, and Texas now say they face budget cuts and layoffs. Public health experts warn the accompanying service cuts — functions like contact tracing, immunizations, family planning, restaurant inspections, and more — could send communities into crisis.

In California, Democratic Gov. Gavin Newsom proposed cutting the state’s public health funding by $300 million. And the Washington Department of Health slashed more than 350 positions at the end of last year and anticipated cutting 349 more this year as the state’s federal covid funding runs dry.

“You cannot hire the firefighters when the house is already burning,” said Brian Castrucci, president and CEO of the de Beaumont Foundation, an organization that advocates for public health policy.

In some places, that pandemic cash did little more than keep small health departments afloat. The Central Montana Health District, the public health agency for five rural counties, did not receive the same flood of money others saw but did get enough to help the staff respond to an increased workload, including testing, contact tracing, and rolling out covid vaccines.

The department filled a vacancy with a federal grant funneled through the state when a staffer left during the pandemic. The federal funding allowed the department to break even, said Susan Woods, the district’s public health director.

Now, there are five full-time employees working for the health district. Woods said the team is getting by with its slim resources, but a funding dip or another public health emergency could tip the balance in the wrong direction.

“Any kind of crisis, any kind of, God forbid, another pandemic, would probably send us crashing,” Woods said.

Adriane Casalotti, chief of government and public affairs for the National Association of County and City Health Officials, said she expects to see layoffs and health department budget cuts intensify. Those cuts will come as health officials address issues that took a back seat during the pandemic, like increases in rates of sexually transmitted diseases, suicide, and substance misuse.

“There’s tons of work being done right now to pick up the pieces on those types of other public health challenges,” she said. But it’ll be hard to catch up with whittled resources.

From 2018 to 2022, reports of chlamydia, gonorrhea, syphilis, and congenital syphilis increased by nearly 2% nationwide, adding up to more than 2.5 million cases. A recent KFF report found that routine vaccination rates for kindergarten-age children have not rebounded to pre-pandemic levels while the number of families claiming exemptions has increased. Nearly three-quarters of states did not meet the federal target vaccination rate of 95% for the 2022-23 school year for measles, mumps, and rubella, increasing the risk of outbreaks.

Amid these challenges, public health leaders are clinging to the resources they gained during the past few years.

The health district in Lubbock, Texas, a city of more than 250,000 people in the state’s Panhandle, hired four disease intervention specialists focused on sexually transmitted diseases during the pandemic due to a five-year grant from the Centers for Disease Control and Prevention.

The positions came as syphilis cases in the state skyrocket past levels seen in the past decade and the increases in congenital syphilis surpass the national average, according to the CDC. State officials recorded 922 congenital syphilis cases in 2022, with a 246.8 rate per 100,000 live births.

But federal officials, facing their own shrinking budget, cut the grant short by two years, leaving the district scrambling to fill a nearly $400,000 annual budget gap while working to tamp down the outbreak.

“Even with the funding, it’s very hard for those staff to keep up with cases and to actually make sure that we get everybody treated,” said Katherine Wells, director of public health for Lubbock.

Wells said state officials may redirect other federal money from the budget to keep the program going when the grant ends in December. Wells and other health leaders in the state consistently plead with state officials for more money but, Wells said, “whether or not we’ll be successful with that in a state like Texas is very much in the air.”

Making public health a priority in the absence of a national crisis is a challenge, Castrucci said. “The boom-and-bust funding cycle is a reflection of the attention of the American public,” he said; as the emergency sunsetted, so too did enthusiasm wane for public health issues.

And rural health departments, like the one in central Montana, deserve more attention, said Casalotti, the advocate for county and city health officials. That’s because they serve a critical function in communities that continue to see hospital closures and lose other health services, such as maternity and women’s care. Local health departments can function as a “safety net for the safety net,” she said.

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Ahora, esa escasez se ha convertido en realidad, y los gobiernos estatales están destinando menos recursos a los departamentos de salud locales.

Ante la pandemia, el Congreso asignó más de $800 mil millones para fortalecer la respuesta de los estados ante covid. Esto resultó en un notable aumento del número de trabajadores de salud pública en todo el país.

El personal de las áreas de salud locales creció alrededor del 19% entre 2019 y 2022, según un informe de la Asociación Nacional de Funcionarios de Salud de Condados y Ciudades que analizó 2,512 de los aproximadamente 3,300 departamentos locales en todo el país.

Ese mismo informe explicaba que, en 2022, la mitad de los ingresos de las oficinas de salud pública regionales provino de fuentes federales.

Pero, a medida que desaparece el dinero, esos puestos de trabajo y la red de apoyo que brinda a las comunidades que atienden se vuelven más frágiles.

Esta situación genera una gran preocupación en los responsables de la salud pública, especialmente en las zonas rurales escasamente pobladas, donde ya se trabaja con pocos recursos, arrastrando disparidades de larga data en la atención de la salud.

En estados como Montana, California, Washington y Texas, los funcionarios enfrentan restricciones presupuestarias y despidos. Expertos en salud pública advierten que los recortes en servicios como el rastreo de contactos, los programas de vacunación, la planificación familiar, las inspecciones de restaurantes y otros podrían poner a las comunidades en situaciones de crisis

En California, el gobernador demócrata Gavin Newsom propuso recortar $300 millones de los fondos para la salud pública. El Departamento de Salud de Washington eliminó más de 350 puestos de trabajo a finales del año pasado, y planea recortar otros 349 este año, a medida que se agotan los fondos federales para covid que recibió el estado.

“No se pueden contratar bomberos cuando la casa ya está ardiendo”, afirmó Brian Castrucci, presidente y director ejecutivo de la Fundación Beaumont, una organización que promueve las políticas de salud pública.

En algunos lugares, el dinero recibido durante la pandemia hizo poco más que mantener a flote los pequeños departamentos de salud. El Distrito Sanitario Central de Montana, una agencia de salud pública que cubre cinco condados rurales, no recibió la misma cantidad de dinero que otros, pero sí lo suficiente como para que el personal pudiera responder a una mayor carga de trabajo, incluyendo testeos, rastreo de contactos y distribución de vacunas contra covid.

El departamento cubrió una vacante con una subvención federal canalizada a través del estado cuando, durante la pandemia, un miembro del personal renunció a su trabajo. La financiación federal permitió que el departamento llegara a un punto de equilibrio, dijo Susan Woods, directora de salud pública del distrito.

Ahora, el distrito tiene cinco empleados a tiempo completo. Woods explicó que el equipo está gestionando con recursos limitados y que otra emergencia de salud pública podría desestabilizar a situación.

“Cualquier tipo de crisis, cualquier nueva pandemia, Dios no lo quiera, probablemente nos haría colapsar”, advirtió Woods.

Adriane Casalotti, jefa de asuntos públicos y gubernamentales de la Asociación Nacional de Funcionarios de Salud de Condados y Ciudades, admitió que es posible que haya más despidos y recortes de dinero.

Esos recortes se producen mientras los funcionarios de salud están tratando de resolver cuestiones muy importantes que quedaron relegadas durante la pandemia, como el aumento de las tasas de enfermedades de transmisión sexual, suicidios y adicciones.

“Hay mucho por hacer para enfrentar estos otros problemas de salud pública que quedaron en un segundo plano”, explicó. Pero será difícil ponerse al día si los recursos de los que se dispone son cada vez más escasos.

Entre 2018 y 2022, los informes mostraron un significativo incremento de las enfermedades de transmisión sexual. Por ejemplo, la clamidia, la gonorrea, la sífilis y la sífilis congénita aumentaron casi un 2% en todo el país, sumando más de 2,5 millones de casos.

Un informe reciente del KFF reveló que las tasas de vacunación en niños de edad preescolar no han recuperado los niveles anteriores a la pandemia. Y aumentó el número de familias que solicitan que se excuse a sus hijos de los programas de vacunación.

Casi tres cuartas partes de los estados no alcanzaron la tasa del 95% de vacunación contra el sarampión, las paperas y la rubéola propuesta por el gobierno federal para el año escolar 2022-23. Este déficit aumenta el riesgo de brotes.

En medio de estos desafíos, las autoridades de salud pública se aferran a los recursos obtenidos durante los últimos años.

El distrito sanitario de Lubbock, Texas, una ciudad de más de 250.000 habitantes situada en el Panhandle del estado, contrató durante la pandemia a cuatro especialistas en enfermedades de transmisión sexual gracias a una subvención por cinco años otorgada por los Centros para el Control y la Prevención de Enfermedades (CDC).

Esos puestos se han creado debido a que los casos de sífilis en Texas se han disparado por encima de los niveles registrados en la última década y, según los CDC, el aumento de la sífilis congénita superó la media nacional.

En 2022, los registros oficiales detectaron 922 casos de sífilis congénita, con una tasa de 246,8 por cada 100.000 nacidos vivos.

Pero los funcionarios federales, que están expuestos a su propia reducción presupuestaria, recortaron la subvención dos años antes de lo previsto. Esto dejó al distrito luchando por subsanar un déficit presupuestario anual de casi $ 400,000 mientras trabajaban para controlar el brote.

“Incluso cuando se recibe financiamiento es muy difícil para el personal de salud sostener el seguimiento de los casos ya detectados y asegurarse de que todos reciben tratamiento”, dijo Katherine Wells, directora de salud pública de Lubbock.

Wells comentó que es probable que, en diciembre, cuando la subvención termine, los funcionarios estatales reorienten otros aportes federales para mantener el programa en marcha.

“Si tendremos o no éxito en un estado como Texas es algo muy incierto”, admitió Wells. Y subrayó que tanto ella como otras autoridades sanitarias solicitan constantemente más recursos a los funcionarios estatales.

El desafío es que se considere la salud pública como una prioridad aunque no exista una emergencia nacional, opinó Castrucci. “El ciclo de auge y caída de la financiación es un reflejo de la atención del público estadounidense”, agregó. Y explicó que a medida que se extinguió la emergencia por covid también se apagó el entusiasmo por las cuestiones de salud pública.

Los departamentos de salud rurales, como el del centro de Montana, merecen más atención, aseguró Casalotti, defensora de los agentes de salud de condados y ciudades. Porque esos departamentos desempeñan una función esencial en comunidades que siguen sufriendo el cierre de hospitales y la pérdida de muchos servicios de salud, como los de maternidad y atención a la mujer.

Los departamentos de salud locales pueden funcionar como una “red de apoyo para la red de apoyo más amplia”, afirmó.

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American Indians and Alaska Natives face life expectancy about 10 years shorter than the national average and, in early 2020, had a covid-19 infection rate 3½ times that of non-Hispanic Whites.

While tribal health leaders have fought for years for better access to data from federal agencies, the pandemic underscored the urgency of making data available to tribes and tribal epidemiology centers.

But even after the public health emergency put a spotlight on the data inequity, tribal public health officials say not much has changed and they still have trouble accessing data on infectious-disease outbreaks, substance use and suicide.

“We’re being blinded,” said Meghan Curry O’Connell, chief public health officer for the Great Plains Tribal Leaders’ Health Board and a citizen of the Cherokee Nation. O’Connell’s work fighting for greater access to data has been highlighted in recent years as the region faces a devastating and ongoing syphilis outbreak.

In 2022, the Government Accountability Office published a report documenting obstacles keeping federal public health information from tribes, including confusion about data-sharing policies, inconsistent processes for requesting information, poor data quality and strict rules for sensitive data on health issues such as substance misuse.

In one example, officials said that as of November 2021, 10 of the 12 tribal epidemiology centers in the United States had varying levels of access to covid data from the Centers for Disease Control and Prevention. While all 10 were given case surveillance data that included information on positive cases, hospitalizations and deaths, only six said they also had access to covid vaccination data from the Department of Health and Human Services.

The GAO report also found that staffers responding to data requests at HHS, the CDC and the Indian Health Service did not consistently recognize tribal epidemiology centers as public health authorities, forcing some to ask for data as researchers or file public records requests.

HHS officials agreed with all of the recommendations the GAO made as a result of its investigation, and after consulting with tribal leaders, this year published a draft policy outlining the types of data the agency would make available to tribes and tribal epidemiology centers, and establishing expectations for agency staffers about responding to data requests.

Some tribal leaders say the proposal is a step in the right direction but is incomplete. Jim Roberts, senior executive liaison in intergovernmental affairs at the Alaska Native Tribal Health Consortium, a nonprofit organization that provides care and advocacy for Alaskan tribes, said the GAO report didn’t address how federal agencies treat tribal governments, which also have a right to their data as sovereign nations.

While HHS continues to work on its policy, Roberts said a strong federal policy on data-use agreements would help tribes’ relationships with state governments, too.

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