npr--2020-01-22--Election Security Boss: Threats To 2020 Are Now Broader, More Diverse

Election Security Boss : Threats To 2020 Are Now Broader , More Diverse Threats to U.S. elections this year could be broader and more diverse than before , warns the spy world 's boss for election security — and she also acknowledged the limits of her ability to tackle them .
Shelby Pierson , the intelligence community 's election threats executive , told NPR in an exclusive interview that more nations may attempt more types of interference in the United States given the extensive lessons that have since been drawn about the Russian attack on the 2016 presidential election .
@ @ @ @ @ @ @ , '' she told Noel King on Morning Edition .
`` We 're still also concerned about China , Iran , non-state actors , 'hacktivists . '
And frankly ... even Americans might be looking to undermine confidence in the elections . ''
But the U.S. intelligence community is n't standing still , Pierson said .
It too has been working since 2016 to learn what lessons it can from that year and also adapt in real time as others do to the way officials at every level plan for this year 's @ @ @ @ @ @ @ it is broader and more diverse simply because we might have more actors than we had in 2016 and we might be looking at different inroads — not just necessarily capitalizing on social media , but also interfering in networks or the vote count , '' she said .
`` So you really have a broader waterfront than you might have had in 2016 . ''
Pierson said that the intelligence community is expanding its technical capabilities and trying to develop more human sources to alert it to interference efforts , but there @ @ @ @ @ @ @ what it can achieve and the efficacy of foreign interference .
First is the tension over what spies should reveal about what they know , how much and when .
Second , the reality that each person forms her or his own perceptions about democracy , whether an election is `` rigged '' or whether a fact is reliable .
Critics faulted the administration of President Obama for keeping quiet through much of 2016 about what it was uncovering about the campaign of active measures that Russia waged that year , including via @ @ @ @ @ @ @ said the intelligence community today is conscious about that lesson and appreciates the possibility that it may need to work quicker to decide how and when to reveal information about potential threats .
But these decisions are n't simple .
Intelligence officials need to preserve sources and methods and do n't want to needlessly sow more mistrust in democracy , she said .
`` Some of my colleagues have said , 'maybe we should n't necessarily spook the herd and share all this information ... Maybe people go , 'You know what , @ @ @ @ @ @ @ so much disinformation .
I 'm not going to vote . '
That would be worst case scenario .
And frankly , doing the work of our adversaries for them . ''
At the same time , the intelligence community says it wants to do more to work with officials at every level .
The FBI , for example , recently expanded its policy for making notifications when it detects a cyberattack .
Pierson also told NPR that it may sometimes be valid to expose a foreign interference operation in the interest of @ @ @ @ @ @ @ prompting Americans not to become cynical but just the opposite — to lean forward and engage .
`` I 've really taken some some very important suggestions to heart that transparency enables resilience and , potentially , sunlight is the best disinfectant , '' she said .
Continued Pierson : `` The more that we talk about the threat , potentially more we empower voters to understand this as merely a reality of today 's landscape .
And that despite all of those challenges , we 're managing them or countering them .
@ @ @ @ @ @ @ '' Pierson was appointed election threats executive under the Office of the Director of National Intelligence in one of the final acts of then-DNI Dan Coats before he was hustled out of the Trump administration last year .
That position has been empty since and the vacant DNI has come to symbolize the lingering antipathy between President Trump and the spy bureaucracy .
Trump not only has never appeared simpatico with much of the intelligence world , he has reserved particular scorn for election security itself .
Trump goes back and forth as @ @ @ @ @ @ @ of 2016 and also has adopted conspiracy theories about it , including one which forms the basis of the ongoing impeachment saga in the Senate .
None of the political backdrop in Washington affects Pierson and her work , she told NPR .
ODNI and the intelligence community have the funding they need , the authorities they need from Congress — and Trump also plays ball when asked , she said .
For example , intelligence and foreign policy specialists asked Trump to warn Russian Foreign Minister Sergey Lavrov against interfering in the @ @ @ @ @ @ @ he agreed .
Lavrov , however , later denied it came up .
The bottom line , as NPR 's King asked Pierson , was this : `` You do n't feel yourself having to work around President Trump ? ''
`` Not at all , '' Pierson said .
There are limits to what the intelligence community can do to address a problem that ultimately manifests itself in the hearts of Americans .
One objective of active measures is simply to spread chaos and sow doubt , and Pierson said she hoped @ @ @ @ @ @ @ on confronting that by citizens , news organizations and beyond .
`` This is where it 's not only a whole of government effort , but frankly a whole of society effort , '' Pierson said .
`` Not only do we want to improve media literacy so that Americans know where to find accurate information to inform their vote and how to spot disinformation if it 's coming through on their own media feeds ... '' She continued : `` ...
I think combating that type of activity , again , is @ @ @ @ @ @ @ can include technical operations sponsored by the intelligence community , working in close partnership with tech firms and social media firms , and as well as coupled with media literacy .
I think that frankly creates our best chance at societal resilience against these threats . ''

Election Security Boss: Threats To 2020 Are Now Broader, More Diverse
Enlarge this image toggle caption Kisha Ravi/NPR Kisha Ravi/NPR
Threats to U.S. elections this year could be broader and more diverse than before, warns the spy world's boss for election security — and she also acknowledged the limits of her ability to tackle them.
Shelby Pierson, the intelligence community's election threats executive, told NPR in an exclusive interview that more nations may attempt more types of interference in the United States given the extensive lessons that have since been drawn about the Russian attack on the 2016 presidential election.
"This isn't a Russia-only problem," she told Noel King on Morning Edition. "We're still also concerned about China, Iran, non-state actors, 'hacktivists.' And frankly ... even Americans might be looking to undermine confidence in the elections."
But the U.S. intelligence community isn't standing still, Pierson said. It, too, has been working since 2016 to learn what lessons it can from that year and also adapt in real time as others do to the way officials at every level plan for this year's presidential race.
I do think it is broader and more diverse simply because we might have more actors than we had in 2016 and we might be looking at different inroads.
"I do think it is broader and more diverse simply because we might have more actors than we had in 2016 and we might be looking at different inroads — not just necessarily capitalizing on social media, but also interfering in networks or the vote count," she said. "So you really have a broader waterfront than you might have had in 2016."
Pierson said that the intelligence community is expanding its technical capabilities and trying to develop more human sources to alert it to interference efforts, but there are two major factors that complicate both what it can achieve and the efficacy of foreign interference.
First is the tension over what spies should reveal about what they know, how much and when. Second, the reality that each person forms her or his own perceptions about democracy, whether an election is "rigged" or whether a fact is reliable.
Critics faulted the administration of President Barack Obama for keeping quiet through much of 2016 about what it was uncovering about the campaign of active measures that Russia waged that year, including via cyberattacks and with online agitation.
Pierson said the intelligence community today is conscious about that lesson and appreciates the possibility that it may need to work quicker to decide how and when to reveal information about potential threats. But these decisions aren't simple.
Intelligence officials need to preserve sources and methods and don't want to needlessly sow more mistrust in democracy, she said.
"Some of my colleagues have said, 'maybe we shouldn't necessarily spook the herd and share all this information ... Maybe people go, 'You know what, this is all rigged. That's so much disinformation. I'm not going to vote.' That would be worst case scenario. And frankly, doing the work of our adversaries for them."
At the same time, the intelligence community says it wants to do more to work with officials at every level. The FBI, for example, recently expanded its policy for making notifications when it detects a cyberattack.
Pierson also told NPR that it may sometimes be valid to expose a foreign interference operation in the interest of educating voters and, she hopes, prompting Americans not to become cynical but just the opposite — to lean forward and engage.
"I've really taken some some very important suggestions to heart that transparency enables resilience and, potentially, sunlight is the best disinfectant," she said.
Continued Pierson: "The more that we talk about the threat, potentially more we empower voters to understand this as merely a reality of today's landscape. And that despite all of those challenges, we're managing them or countering them. And [people] should vote."
View from within ODNI
Pierson was appointed election threats executive under the Office of the Director of National Intelligence in one of the final acts of then-DNI Dan Coats before he was hustled out of the Trump administration last year.
That position has been empty since and the vacant DNI has come to symbolize the lingering antipathy between President Trump and the spy bureaucracy.
Trump not only has never appeared simpatico with much of the intelligence world, he has reserved particular scorn for election security itself. Trump goes back and forth as to what he accepts about the events of 2016 and also has adopted conspiracy theories about it, including one which forms the basis of the ongoing impeachment saga in the Senate.
None of the political backdrop in Washington affects Pierson and her work, she told NPR. ODNI and the intelligence community have the funding they need, the authorities they need from Congress — and Trump also plays ball when asked, she said.
For example, intelligence and foreign policy specialists asked Trump to warn Russian Foreign Minister Sergey Lavrov against interfering in the 2020 election, Pierson said — and he agreed. Lavrov, however, later denied it came up.
The bottom line, as NPR's King asked Pierson, was this: "You don't feel yourself having to work around President Trump?"
"Not at all," Pierson said.
National conversation
There are limits to what the intelligence community can do to address a problem that ultimately manifests itself in the hearts of Americans.
One objective of active measures is simply to spread chaos and sow doubt, and Pierson said she hoped the coming year would bring a focus on confronting that by citizens, news organizations and beyond.
"This is where it's not only a whole of government effort, but frankly a whole of society effort," Pierson said.
"Not only do we want to improve media literacy so that Americans know where to find accurate information to inform their vote and how to spot disinformation if it's coming through on their own media feeds ..."
She continued: "... I think combating that type of activity, again, is a full spectrum of opportunities, which can include technical operations sponsored by the intelligence community, working in close partnership with tech firms and social media firms, and as well as coupled with media literacy. I think that frankly creates our best chance at societal resilience against these threats."


npr--2020-01-22--Northwest Salmon In Peril, And Efforts To Save Them Scale Up

Northwest Salmon In Peril , And Efforts To Save Them Scale Up This past fall , Idaho officials took the extraordinary step of closing the Clearwater River to salmon and steelhead trout fishing , leaving guides like Jeremy Sabus scrambling to find other work .
`` It 's six weeks of my favorite time of the year , you get to shake hands with 3-foot trout , '' Sabus says .
Billed as one of the top destinations for salmon fishing in the United States , the Clearwater cuts through steep gorges in northern Idaho before dumping into the Snake @ @ @ @ @ @ @ year , salmon and steelhead make an epic 500-mile or longer journey upstream from the ocean to spawn .
But this winter their runs are among the lowest they 've been in a century .
It 's never been easy for the famed fish .
They have to navigate a series of dams that support the region 's hydropower grid and irrigation and barges for agriculture .
These slow down river flows in places , warm the water and make the trout more vulnerable to predators .
But the situation is now being @ @ @ @ @ @ @ warming the Pacific Ocean and increasing acidity levels .
One federal scientist recently estimated that if nothing more is done to save the salmon and steelhead across the Columbia River basin , some of the species will go extinct within 20 years .
This has added urgency in long-running efforts to save the salmon .
It 's also reopened a bitter , 30-year legal battle over the fish and the rivers it depends on .
`` The problem is that now we 're fighting an issue that we do n't have much control @ @ @ @ @ @ @ says Lizzy McKeag , a field organizer with the Idaho Wildlife Federation .
On the Clearwater , the fishing closure was lifted a couple weeks ago , partly due to improved hatchery numbers , but most of the outfitters ' clients had already canceled .
`` I was just purely sad , '' Sabus says , referring to both the environmental and economic fallouts .
Standing on a concrete boat ramp near the town of Orofino , Sabus is washing off his fiberglass drift boat after a morning on the river .
He @ @ @ @ @ @ @ here or there , but mostly it feels eerily empty here .
`` Driving all the way from Lowell , Idaho , to Lewiston and not seeing any boats , in the 23 years I 've been fishing I have n't ever seen that , '' Sabus says .
That 's about a 70-mile stretch of famed trout stream on U.S. Highway 12 , which meanders through old growth fir and pine forests and steep grassy gorges following the old Lewis and Clark Trail .
Hotel bookings in the area have cratered , @ @ @ @ @ @ @ by Clearwater County estimated the economic hit of the closure at around $ 8 million a month .
That 's huge for this rural , sparsely populated area , home to small , struggling river towns that used to depend on timber and now lean heavily on fishing , hunting and boating dollars especially in winter .
But folks here also rely on the relatively cheap power thanks to the dams , in particular four of them on the Lower Snake River that conservationists and Native American tribes want removed .
`` The @ @ @ @ @ @ @ how resilient they are , '' conservationist Lizzy McKeag says .
`` If we just give them half a chance they 're going to take advantage of that . ''
McKeag , who lives in the farming hub of Grangeville , sees the recent fishing closure as a possible tipping point that breaks a 30-year legal stalemate .
The fight has pitted people against one another in towns that depend on the salmon , cheap power and a water system that allows farmers to easily grow and export wheat .
`` I think @ @ @ @ @ @ @ and steelhead issue is that all of those economies are now interconnected , especially in these small towns , '' McKeag says .
And for the first time in years , interests long diametrically opposed to one another are at least getting together and talking .
The governors of Idaho and Washington have convened task forces to find legislative fixes .
And conservationists are appearing alongside farmers and energy industry officials at public meetings in the region .
There 's a sense that people are tired of the lawsuits .
`` We consider @ @ @ @ @ @ @ Connolly , a vice president at the Bonneville Power Administration .
BPA is the federal agency that markets and sells hydropower from the dams .
Connolly is not committing to removing the four dams in question on the Snake River ( below the Clearwater in Washington state ) .
But that question is at the heart of the latest court-ordered federal environmental review that 's expected to be released in draft next month .
`` We 're really trying to listen to our critics and say , how can we get together around @ @ @ @ @ @ @ make things better for the fish , '' Connolly says .
`` That 's what we 're trying to do . ''
These 13 species of salmon and steelhead were first listed as threatened on the Endangered Species Act after a lawsuit from Native American tribes in the 1990s , and since then BPA and other agencies have spent tens of millions of dollars on mitigation .
The money goes to everything from habitat restoration , fish ladders to get around the dams hatcheries .
Today an estimated 80 % of the fish @ @ @ @ @ @ @ And yet the salmon continue to decline , from historical numbers of 18 million in the 1800s to barely 2 million today .
For tribes , this represents another broken promise with the U.S. government .
McCoy Oatman , a tribal councilman for the Nez Perce , says his people depended on the fish for nutrition and survival before being forced onto a reservation that today only includes a stretch of the Clearwater River .
`` We want to be healthy individuals like our ancestors , '' Oatman says .
`` When our @ @ @ @ @ @ @ natural foods that has an impact on us as a people . ''
Diseases such as diabetes are disproportionately high on the reservation .
But he sees hope in the fact that some dams are being removed in other parts of the Northwest right now .
`` You know , I 'm hoping that in my daughters ' lifetime , they 'll be able to see a free flowing Snake River , much like we have on the Salmon River , '' Oatman says .
A free flowing Snake River , he says @ @ @ @ @ @ @ some ancestral fishing grounds for the of the tribe , not to mention the local economy that 's come to depend heavily on the salmon and steelhead .

Northwest Salmon In Peril, And Efforts To Save Them Scale Up
Enlarge this image toggle caption Kirk Siegler/NPR Kirk Siegler/NPR
This past fall, Idaho officials took the extraordinary step of closing the Clearwater River to salmon and steelhead trout fishing, leaving guides like Jeremy Sabus scrambling to find other work.
"It's six weeks of my favorite time of the year, you get to shake hands with 3-foot trout," Sabus says.
Billed as one of the top destinations for salmon fishing in the United States, the Clearwater cuts through steep gorges in northern Idaho before dumping into the Snake and eventually, Columbia rivers. Every year, salmon and steelhead make an epic 500-mile or longer journey upstream from the ocean to spawn.
National In Northern California, Researchers Hope Bugs Will Help Salmon Survive Migration In Northern California, Researchers Hope Bugs Will Help Salmon Survive Migration 4:21
But this winter their runs are among the lowest they've been in a century.
It's never been easy for the famed fish. They have to navigate a series of dams that support the region's hydropower grid and irrigation and barges for agriculture. These slow down river flows in places, warm the water and make the trout more vulnerable to predators.
But the situation is now being exacerbated by climate change, which is warming the Pacific Ocean and increasing acidity levels. One federal scientist recently estimated that if nothing more is done to save the salmon and steelhead across the Columbia River basin, some of the species will go extinct within 20 years.
This has added urgency in long-running efforts to save the salmon. It's also reopened a bitter, 30-year legal battle over the fish and the rivers it depends on.
"The problem is that now we're fighting an issue that we don't have much control over, the changing climate," says Lizzy McKeag, a field organizer with the Idaho Wildlife Federation.
On the Clearwater, the fishing closure was lifted a couple weeks ago, partly due to improved hatchery numbers, but most of the outfitters' clients had already canceled.
"I was just purely sad," Sabus says, referring to both the environmental and economic fallouts.
Standing on a concrete boat ramp near the town of Orofino, Sabus is washing off his fiberglass drift boat after a morning on the river. He's cobbled together a few guided trips here or there, but mostly it feels eerily empty here.
"Driving all the way from Lowell, Idaho, to Lewiston and not seeing any boats, in the 23 years I've been fishing I haven't ever seen that," Sabus says.
Enlarge this image toggle caption Kirk Siegler/NPR Kirk Siegler/NPR
That's about a 70-mile stretch of famed trout stream on U.S. Highway 12, which meanders through old growth fir and pine forests and steep grassy gorges following the old Lewis and Clark Trail. Hotel bookings in the area have cratered, restaurants are unusually quiet. A study by Clearwater County estimated the economic hit of the closure at around $8 million a month.
That's huge for this rural, sparsely populated area, home to small, struggling river towns that used to depend on timber and now lean heavily on fishing, hunting and boating dollars especially in winter. But folks here also rely on the relatively cheap power thanks to the dams, in particular four of them on the Lower Snake River that conservationists and Native American tribes want removed.
"The most amazing thing about these fish is how resilient they are," conservationist Lizzy McKeag says. "If we just give them half a chance they're going to take advantage of that."
McKeag, who lives in the farming hub of Grangeville, sees the recent fishing closure as a possible tipping point that breaks a 30-year legal stalemate. The fight has pitted people against one another in towns that depend on the salmon, cheap power and a water system that allows farmers to easily grow and export wheat.
"I think the beauty and struggle of the salmon and steelhead issue is that all of those economies are now interconnected, especially in these small towns," McKeag says.
And for the first time in years, interests long diametrically opposed to one another are at least getting together and talking. The governors of Idaho and Washington have convened task forces to find legislative fixes. And conservationists are appearing alongside farmers and energy industry officials at public meetings in the region.
Enlarge this image toggle caption Greg Vaughn/VW Pics/Universal Images Group via Getty Images Greg Vaughn/VW Pics/Universal Images Group via Getty Images
There's a sense that people are tired of the lawsuits.
"We consider ourselves salmon advocates," says Kieran Connolly, a vice president at the Bonneville Power Administration.
BPA is the federal agency that markets and sells hydropower from the dams. Connolly is not committing to removing the four dams in question on the Snake River (below the Clearwater in Washington state). But that question is at the heart of the latest court-ordered federal environmental review that's expected to be released in draft next month.
"We're really trying to listen to our critics and say, how can we get together around a table and incorporate your ideas to make things better for the fish," Connolly says. "That's what we're trying to do."
These 13 species of salmon and steelhead were first listed as threatened on the Endangered Species Act after a lawsuit from Native American tribes in the 1990s, and since then BPA and other agencies have spent hundreds of millions of dollars on mitigation.
The money goes to everything from fish ladders to get around the dams to habitat restoration to hatcheries. Today an estimated 80% of the fish on the system stem from hatcheries.
And yet the salmon continue to decline, from historical numbers of 18 million in the 1800s to barely 2 million today.
National Scientists Hope Scents Will Help Hatchery Salmon Return Home To Spawn Scientists Hope Scents Will Help Hatchery Salmon Return Home To Spawn Listen · 3:46 3:46
For tribes, this represents another broken promise with the U.S. government. McCoy Oatman, a tribal councilman for the Nez Perce, says his people depended on the fish for nutrition and survival before being forced onto a reservation that today only includes a stretch of the Clearwater River.
"We want to be healthy individuals like our ancestors," Oatman says. "When our bodies are not able to consume our natural foods that has an impact on us as a people."
Diseases such as diabetes are disproportionately high on the reservation. But he sees hope in the fact that some dams are being removed in other parts of the Northwest right now.
"You know, I'm hoping that in my daughters' lifetime, they'll be able to see a free flowing Snake River, much like we have on the Salmon River," Oatman says.
A free flowing Snake River, he says, would be a step toward restoring some ancestral fishing grounds for the of the tribe, not to mention the local economy that's come to depend heavily on the salmon and steelhead.


npr--2020-01-22--'To Stop Now Would Be Foolish': Doubling Down On Services For High-Cost Patients

'To Stop Now Would Be Foolish ' : Doubling Down On Services For High-Cost Patients A highly publicized approach to lowering health costs failed to pass rigorous study this month , but hospitals , insurers and government health programs do n't intend to give up on the idea .
It just needs to be modified , they say .
The `` hotspotting '' model was pioneered in Camden , N.J. , in 2002 and inspired dozens of similar projects around the country , many financed by millions of dollars from the government and private foundations .
The model focuses on @ @ @ @ @ @ @ homelessness or drug addiction and use the hospital multiple times a year , typically for avoidable complications from chronic diseases .
The participants work with doctors , social workers and nurses for individual help , with the idea of preventing repeat hospitalizations and extra expense down the road .
A study in the New England Journal of Medicine this month confirmed that repeat hospitalizations did indeed drop for participants in the Camden program — but the result was no better in that regard than the results from a group of patients who did @ @ @ @ @ @ @ Many state and federal policymakers across the U.S. initially had been attracted to the Camden model because they saw it as a possible solution for this intractable reality : Just 5 % of patients account for half of all health spending .
So , the disappointing results from Camden have caused some angst among health officials working on the model from Oregon to North Carolina .
`` The study should give everyone who is involved in hotspotting a chance to pause and really reflect on the programs that they are doing , '' @ @ @ @ @ @ @ officer at CareOregon , a large Medicaid managed-care insurer that for a decade has targeted some of these high-cost patients .
But `` to stop now would be foolish , '' says Susan Cooper , chief integration officer for Regional One Health , a Memphis , Tenn. , health system that launched a program in 2018 based on the Camden model .
The Tennessee program is geared to patients who have the most emergency room and hospital visits because of unmet social needs , such as hunger and housing .
Using nurses and @ @ @ @ @ @ @ these `` super-utilizer '' patients with community resources such as housing , transportation and meals , as well as connecting them to primary care .
From April 2018 through last month nearly 350 people have enrolled in the program and the hospital says that by reducing ER visits and hospital admissions , it has saved more than $ 9 million than it expected to spend on these patients .
A Medicaid experiment similar to the Camden approach is also expanding in California , the most populous state in the nation .
As part @ @ @ @ @ @ @ California Gov .
Gavin Newsom wants to add $ 582.5 million to Medi-Cal , the state 's Medicaid program , to increase intensive , comprehensive care management to high-needs , high-risk patients — especially homeless people or those getting out of jail .
If approved by the state legislature , the infusion would also fund services designed to decrease these patients ' reliance on expensive hospital visits and emergency service transportation .
These Whole Person Care programs provide participants with social and medical services , such as substance abuse treatment and recuperative care @ @ @ @ @ @ @ helping people who need the extra support to get stable housing .
'It ca n't just be medically focused' The Camden Coalition study highlights the need for more focus on social services , says Dr. Clemens Hong , director of the Whole Person Care pilot in Los Angeles .
That program has served more than 46,000 people and has a five-year budget of more than $ 1 billion , made up of federal and local funds .
The cost of these supportive programs is high , Hong says , because California is creating @ @ @ @ @ @ @ connecting people to existing programs .
For instance , the Los Angeles Fire Department operates a dedicated ambulance unit for Skid Row to bring some intoxicated people to a sobering center instead of the emergency room .
There , they can rest and get access to substance abuse treatment and other services .
`` One of the key lessons is that it ca n't just be medically focused , '' Hong says about the results of the Camden Coalition study .
Camden Coalition officials agree .
They say that although their work was @ @ @ @ @ @ @ net services , they learned that sometimes those resources were not available .
The coalition now has expanded its outreach and set up more partnerships , including efforts to start a housing program .
Hong says measuring only readmissions is n't enough to judge impact .
Rather , he says , evaluations should consider how well the programs increase employment , treat addiction or reduce time spent living on the street .
The Camden Coalition , which provided services for 194 people last year , was founded by Dr. Jeffrey Brenner , a @ @ @ @ @ @ @ improve health care in one of the poorest cities in the country .
Using medical billing data from hospitals in Camden , Brenner located `` hot spots '' that had larger numbers of high-cost patients — even down to the city block .
These patients , he found , repeatedly showed up in emergency rooms and doctors ' offices .
They often had physical health issues such as diabetes , asthma and other chronic illnesses that were compounded by psychological and social issues such as anxiety and homelessness .
The first studies of @ @ @ @ @ @ @ services before and after being enrolled in a program that offered them this sort of extra support .
By coordinating the medical care and social services the patients needed , Brenner and his group were able to cut down on the number of rehospitalizations .
Indeed , a New England Journal of Medicine study published Jan. 9 , conducted by researchers at the Massachusetts Institute of Technology , confirmed that the program over six months reduced readmissions by nearly 40 % .
But a group of similar patients who did not get the @ @ @ @ @ @ @ .
This type of randomized-control trial , the gold standard in clinical medicine , is rarely used in health policy studies , partly due to the cost .
Shah , of CareOregon , says the study results prove there is no single solution that will work in every community for every type of patient .
`` There is no one magic bullet , '' Shah says .
`` The study confirmed there is a population of super-utilizers that will not go away '' just through these community efforts alone .
He stressed local @ @ @ @ @ @ @ needed to fix social and legal challenges that influence patients ' health .
Camden Coalition officials say the results were disappointing , but noted they have made major changes to their efforts since the study trial ended in 2017 .
This includes efforts to help participants find stable housing and legal services to break down barriers to Medicaid and other benefits .
`` We have already made some pivots , '' says the coalition 's CEO , Kathleen Noonan .
She says people should not take away from the study `` that focusing @ @ @ @ @ @ @ those efforts are moot . ''
The study showed some positive benefits , including how participants were more likely to obtain food stamp benefits compared with those in the control group .
`` To paraphrase Mark Twain , reports of the death of the hotspotting model are greatly exaggerated , '' says Rutgers University professor Joel Cantor , director of the Center for State Health Policy , who has worked closely with the coalition .
`` This is a single study , focusing mainly on one of many possible outcomes , in a @ @ @ @ @ @ @ won a MacArthur Foundation fellowship — known as a `` genius '' grant — in 2013 , says hotspotting efforts need to keep evolving .
`` There are glimmers of things that work , and we need to keep at this .
It is a solvable problem , '' says Brenner .
When he first started the coalition , Brenner says , he hoped just helping people navigate the health system would improve their health and lower costs .
But that approach faced shortcomings when services such as addiction treatment and housing assistance @ @ @ @ @ @ @ as simple as just navigating and coordinating , '' he says .
Kaiser Health News is a nonprofit , editorially independent program of the Kaiser Family Foundation .
KHN is not affiliated with Kaiser Permanente .

'To Stop Now Would Be Foolish': Doubling Down On Services For High-Cost Patients
Enlarge this image toggle caption Oivind Hovland/Ikon Images/Getty Images Oivind Hovland/Ikon Images/Getty Images
A highly publicized approach to lowering health costs failed to pass rigorous study this month, but hospitals, insurers and government health programs don't intend to give up on the idea. It just needs to be modified, they say.
The "hotspotting" model was pioneered in Camden, N.J., in 2002 and inspired dozens of similar projects around the country, many financed by millions of dollars from the government and private foundations. The model focuses on people who face social barriers such as homelessness or drug addiction and use the hospital multiple times a year, typically for avoidable complications from chronic diseases. The participants work with doctors, social workers and nurses for individual help, with the idea of preventing repeat hospitalizations and extra expense down the road.
A study in the New England Journal of Medicine this month confirmed that repeat hospitalizations did indeed drop for participants in the Camden program — but the result was no better in that regard than the results from a group of patients who did not get the intensive care coordination.
Many state and federal policymakers across the U.S. initially had been attracted to the Camden model because they saw it as a possible solution for this intractable reality: Just 5% of patients account for half of all health spending.
So, the disappointing results from Camden have caused some angst among health officials working on the model from Oregon to North Carolina.
"The study should give everyone who is involved in hotspotting a chance to pause and really reflect on the programs that they are doing," says Dr. Amit Shah, chief medical officer at CareOregon, a large Medicaid managed-care insurer that for a decade has targeted some of these high-cost patients.
But "to stop now would be foolish," says Susan Cooper, chief integration officer for Regional One Health, a Memphis, Tenn., health system that launched a program in 2018 based on the Camden model. The Tennessee program is geared to patients who have the most emergency room and hospital visits because of unmet social needs, such as hunger and housing.
Using nurses and social workers, the hospital pairs up these "super-utilizer" patients with community resources such as housing, transportation and meals, as well as connecting them to primary care. From April 2018 through last month nearly 350 people have enrolled in the program and the hospital says that by reducing ER visits and hospital admissions, it has saved more than $9 million than it expected to spend on these patients.
A Medicaid experiment similar to the Camden approach is also expanding in California, the most populous state in the nation.
As part of his 2020-21 state budget proposal, California Gov. Gavin Newsom wants to add $582.5 million to Medi-Cal, the state's Medicaid program, to increase intensive, comprehensive care management to high-needs, high-risk patients — especially homeless people or those getting out of jail. If approved by the state legislature, the infusion would also fund services designed to decrease these patients' reliance on expensive hospital visits and emergency service transportation.
These Whole Person Care programs provide participants with social and medical services, such as substance abuse treatment and recuperative care after hospital stays, as well as helping people who need the extra support to get stable housing.
'It can't just be medically focused'
The Camden Coalition study highlights the need for more focus on social services, says Dr. Clemens Hong, director of the Whole Person Care pilot in Los Angeles. That program has served more than 46,000 people and has a five-year budget of more than $1 billion, made up of federal and local funds.
The cost of these supportive programs is high, Hong says, because California is creating services for participants, in addition to connecting people to existing programs. For instance, the Los Angeles Fire Department operates a dedicated ambulance unit for Skid Row to bring some intoxicated people to a sobering center instead of the emergency room. There, they can rest and get access to substance abuse treatment and other services.
"One of the key lessons is that it can't just be medically focused," Hong says about the results of the Camden Coalition study.
Camden Coalition officials agree. They say that although their work was originally designed to help people find safety net services, they learned that sometimes those resources were not available. The coalition now has expanded its outreach and set up more partnerships, including efforts to start a housing program.
Other measures of success
Hong says measuring only readmissions isn't enough to judge impact. Rather, he says, evaluations should consider how well the programs increase employment, treat addiction or reduce time spent living on the street.
The Camden Coalition, which provided services for 194 people last year, was founded by Dr. Jeffrey Brenner, a family doctor, who was looking to improve health care in one of the poorest cities in the country.
Using medical billing data from hospitals in Camden, Brenner located "hot spots" that had larger numbers of high-cost patients — even down to the city block. These patients, he found, repeatedly showed up in emergency rooms and doctors' offices. They often had physical health issues such as diabetes, asthma and other chronic illnesses that were compounded by psychological and social issues such as anxiety and homelessness.
The first studies of the initiative primarily measured how patients used services before and after being enrolled in a program that offered them this sort of extra support.
By coordinating the medical care and social services the patients needed, Brenner and his group were able to cut down on the number of rehospitalizations.
Indeed, a New England Journal of Medicine study published Jan. 9, conducted by researchers at the Massachusetts Institute of Technology, confirmed that the program over six months reduced readmissions by nearly 40%. But a group of similar patients who did not get the interventions had a similar drop in rehospitalizations.
This type of randomized-control trial, the gold standard in clinical medicine, is rarely used in health policy studies, partly due to the cost.
Shah, of CareOregon, says the study results prove there is no single solution that will work in every community for every type of patient.
"There is no one magic bullet," Shah says. "The study confirmed there is a population of super-utilizers that will not go away" just through these community efforts alone. He stressed local, state and federal policy changes are needed to fix social and legal challenges that influence patients' health.
Camden Coalition officials say the results were disappointing, but noted they have made major changes to their efforts since the study trial ended in 2017. This includes efforts to help participants find stable housing and legal services to break down barriers to Medicaid and other benefits.
"We have already made some pivots," says the coalition's CEO, Kathleen Noonan.
She says people should not take away from the study "that focusing on social determinants of health and all those efforts are moot." The study showed some positive benefits, including how participants were more likely to obtain food stamp benefits compared with those in the control group.
"To paraphrase Mark Twain, reports of the death of the hotspotting model are greatly exaggerated," says Rutgers University professor Joel Cantor, director of the Center for State Health Policy, who has worked closely with the coalition. "This is a single study, focusing mainly on one of many possible outcomes, in a single location."
Brenner, who won a MacArthur Foundation fellowship — known as a "genius" grant — in 2013, says hotspotting efforts need to keep evolving.
"There are glimmers of things that work, and we need to keep at this. It is a solvable problem," says Brenner.
When he first started the coalition, Brenner says, he hoped just helping people navigate the health system would improve their health and lower costs. But that approach faced shortcomings when services such as addiction treatment and housing assistance were lacking.
"It's not as simple as just navigating and coordinating," he says.
Kaiser Health News is a nonprofit, editorially independent program of the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.


npr--2020-01-22--Some Push To Change State Laws That Require HIV Disclosure To Sexual Partners

Some Push To Change State Laws That Require HIV Disclosure To Sexual Partners In more than 30 states , it is illegal for someone with HIV to have sex without first disclosing their status .
Some are now pushing to change that , arguing that the laws are actually endangering public health .
More than 1 million people in the U.S. are living with HIV , and their HIV status could conceivably put them behind bars .
That 's what happened to Michael Holder .
`` I served 8 1/2 years in prison and three years after on parole , @ @ @ @ @ @ @ , Holder 's ex-girlfriend testified that he did n't disclose his HIV status before they had sex .
That 's a crime in Michigan and in most states in the country .
He says the day after she said that , she came in and recanted .
`` She testified the truth and said that she had lied and said that she was jealous , and she loved me and that I had told her just like I had testified and said I 'd told her , '' Holder says .
`` And @ @ @ @ @ @ @ was too late . ''
Holder could n't prove that he told her .
Public health experts say that 's one of many problems with HIV criminalization laws .
Ohio , Tennessee and Florida are the top prosecutors , charging more than 120 people in the last decade .
`` Would you want to have to disclose your sexual practices and your personal health in front of a medical professional and your partner ? ''
asks Daphne Kackloudis , of the Ohio Health Modernization Movement .
`` I do n't think anyone wants @ @ @ @ @ @ @ of a third party in order to prove that they 've had the conversation . ''
She 's part of a group of public health experts pushing to change Ohio 's 1999 statute .
`` A lot has happened since 1999 , and lawmakers do n't necessarily know that , '' she says .
`` And let 's be honest .
A lot of citizens , you know , who are n't lawmakers do n't know the advances that have been made in science and the reasons that we believe this law should @ @ @ @ @ @ @ helped turn HIV from a fatal infection into a manageable chronic condition .
The Centers For Disease Control and Prevention recently announced that if people take antiretroviral drugs as prescribed , the amount of HIV in their blood can become undetectable .
If it stays undetectable , they have little risk of passing the virus to a partner through sex , and can live long , healthy lives .
This past June , the American Medical Association called for the total repeal of HIV criminalization .
That sparked action for reforms in Washington @ @ @ @ @ @ @ Tennessee and Florida .
`` The data does n't support that any of these laws that criminalize HIV actually decrease transmission rates , '' says Jada Hicks , with the New York-based Center for HIV Law and Policy .
In some places , the public health push has worked .
California , Iowa and Michigan recently reformed their laws .
Ohio 's statute has been challenged multiple times since it was introduced .
In a 2017 Ohio Supreme Court case , lawyer Samuel Peterson defended the law on behalf of the state .
@ @ @ @ @ @ @ there are two parties to that conduct , '' Peterson said in archival footage .
`` And the other person has a right to know and has a right to be party to the decision to engage in the sexual conduct .
Daphne Kackloudis says she understands that argument , but that 's only one part of the legal puzzle .
`` We would never want someone who intentionally transmits HIV to not be able to be prosecuted under the statute .
We think that 's not right , '' she explains .
@ @ @ @ @ @ @ written , the law puts the burden on people like Michael Holder to prove that they disclosed .
She fears these laws , which intended to stop the spread of HIV , may actually be doing just the opposite , disincentivizing people to know their status in the first place .
`` If they did n't have the law , more people would come in and get tested , you know , '' Holder says .
`` Because they would n't have to risk having done to them what was done to me @ @ @ @ @ @ @ 1 in 7 people with HIV do n't even know they have the virus .

Some Push To Change State Laws That Require HIV Disclosure To Sexual Partners
Enlarge this image Getty Images/Science Photo Libra Getty Images/Science Photo Libra
In more than 30 states, it is illegal for someone with HIV to have sex without first disclosing their status. Some are now pushing to change that, arguing that the laws are actually endangering public health.
More than 1 million people in the U.S. are living with HIV, and their HIV status could conceivably put them behind bars. That's what happened to Michael Holder.
"I served 8 1/2 years in prison and three years after on parole," Holder says.
Back in 2000, Holder's ex-girlfriend testified that he didn't disclose his HIV status before they had sex. That's a crime in Michigan and in most states in the country.
He says the day after she said that, she came in and recanted.
"She testified the truth and said that she had lied and said that she was jealous, and she loved me and that I had told her just like I had testified and said I'd told her," Holder says. "And she told the truth, but it was too late."
Holder couldn't prove that he told her. Public health experts say that's one of many problems with HIV criminalization laws. Ohio, Tennessee and Florida are the top prosecutors, charging more than 120 people in the last decade.
"Would you want to have to disclose your sexual practices and your personal health in front of a medical professional and your partner?" asks Daphne Kackloudis, of the Ohio Health Modernization Movement. "I don't think anyone wants to have that difficult conversation in front of a third party in order to prove that they've had the conversation."
She's part of a group of public health experts pushing to change Ohio's 1999 statute.
"A lot has happened since 1999, and lawmakers don't necessarily know that," she says. "And let's be honest. A lot of citizens, you know, who aren't lawmakers don't know the advances that have been made in science and the reasons that we believe this law should be modernized."
Medical advancements have helped turn HIV from a fatal infection into a manageable chronic condition.
The Centers For Disease Control and Prevention recently announced that if people take antiretroviral drugs as prescribed, the amount of HIV in their blood can become undetectable. If it stays undetectable, they have little risk of passing the virus to a partner through sex, and can live long, healthy lives.
This past June, the American Medical Association called for the total repeal of HIV criminalization. That sparked action for reforms in Washington, Missouri, Georgia, Indiana, Tennessee and Florida.
"The data doesn't support that any of these laws that criminalize HIV actually decrease transmission rates," says Jada Hicks, with the New York-based Center for HIV Law and Policy.
In some places, the public health push has worked. California, Iowa and Michigan recently reformed their laws.
Ohio's statute has been challenged multiple times since it was introduced. In a 2017 Ohio Supreme Court case, lawyer Samuel Peterson defended the law on behalf of the state.
"When you have sexual conduct, there are two parties to that conduct," Peterson said in archival footage. "And the other person has a right to know and has a right to be party to the decision to engage in the sexual conduct.
Daphne Kackloudis says she understands that argument, but that's only one part of the legal puzzle.
"We would never want someone who intentionally transmits HIV to not be able to be prosecuted under the statute. We think that's not right," she explains.
But she says, as it's written, the law puts the burden on people like Michael Holder to prove that they disclosed.
She fears these laws, which intended to stop the spread of HIV, may actually be doing just the opposite, disincentivizing people to know their status in the first place.
"If they didn't have the law, more people would come in and get tested, you know," Holder says. "Because they wouldn't have to risk having done to them what was done to me."
According to the CDC, 1 in 7 people with HIV don't even know they have the virus.


npr--2020-01-22--Supreme Court Considers Religious Schools Case

The U.S. Supreme Court hears arguments Wednesday in a major case that could dramatically alter the line separating church and state .
At issue is a Montana state constitutional amendment that bars direct and indirect taxpayer aid to religious institutions .
Conservative religious groups and advocates of school choice are challenging the `` no-aid '' provision .
They have long sought to invalidate state constitutional amendments that prohibit taxpayer funding from going to religious schools .
Given that Montana is one of 38 states with a `` no-aid '' provision , the court 's eventual decision could have far-reaching consequences @ @ @ @ @ @ @ the Montana legislature passed a bill providing a dollar-for-dollar tax credit for individuals who donate to organizations that provide scholarship money to students in private schools .
An organization called Big Sky began raising money to fund these scholarships , using the tax credit as an incentive .
Of the 13 schools that got scholarship money from Big Sky , 12 were religious schools .
Indeed , 70 percent of all private schools in Montana are religiously affiliated .
Ultimately , the Montana Supreme Court struck down the entire tax credit program for @ @ @ @ @ @ @ alike .
It said the tax credit conflicted with the state constitution , which bars all state aid for religious education , whether direct or indirect , like a tax subsidy .
School choice advocates are now asking the U.S. Supreme Court to revive the scholarship aid program in its entirety .
They are backed by the Trump administration , including Education Secretary Betsy DeVos who as a private citizen and as a Cabinet member has advocated for what she recently called `` faith-based education . ''
Kendra Espinoza , the lead plaintiff @ @ @ @ @ @ @ attending the Stillwater Christian School in Kalispell , Mont .
She is an office manager and staff accountant , who works extra jobs in order to pay for her children 's tuition .
`` I wanted my kids to have a really strong sense of right and wrong from a biblical perspective , '' Espinoza said of her decision to send her children to a religious school .
`` I want them to understand that our sense of ethics and our morals come from God 's word , not just man 's ideas @ @ @ @ @ @ @ the Montana Supreme Court invalidated the tax program `` was because it included religious schools , '' maintains Erica Smith , a senior attorney at the Institute for Justice , which for decades has been fighting to get rid of state constitutional provisions like the one in Montana .
She argues that the federal constitution 's guarantee of equal protection of the law mandates that the tax-credit program be revived and applied equally to all private schools , religious and non-religious alike .
`` Once you have these programs , '' Smith says @ @ @ @ @ @ @ going to religious schools equal to families going to non-religious schools . ''
The state of Montana , however , disagrees .
It defends the state constitutional provision barring direct or indirect state aid , like tax credits , for religious education .
At the heart of the case are what opponents of these `` no-aid '' provisions call `` baby Blaine Amendments , '' named after James G. Blaine , who introduced a similar amendment to the federal constitution in Congress in 1875 .
While the original Blaine amendment failed to pass @ @ @ @ @ @ @ most states .
Many scholars today view the adoption of these amendments , mostly in the late 1800s , as a bigoted reaction to the mass immigration of Catholics into the U.S. Lawyers for Espinoza argue that the Montana amendment , which was originally adopted in the late 1800s , was `` born of '' bigotry against Catholics and therefore that the state 's `` no-aid '' provision discriminates against religion in violation of the federal constitution .
Smith notes that these `` baby Blaine Amendments '' have never been squarely challenged in @ @ @ @ @ @ @ hopes that `` the court will take the opportunity to end the bigotry behind these Blaine amendments . ''
The Montana constitutional amendment , however , is not some relic of the past .
Though the no-aid provision was originally adopted in 1889 , the state constitution was revised and rewritten in 1972 .
All but one of the surviving delegates to that convention have submitted a brief in this case discussing how the `` no-aid '' provision was debated and enacted 48 years ago .
They dispute Smith 's claim that the @ @ @ @ @ @ @ was just a rubber stamp of the 1889 provision .
`` There was clearly some interest being expressed on behalf of the parochial schools to open up the no-aid provision , '' recalls Mae Nan Ellingson , one of the delegates .
She says a daylong hearing was held , with some 100 witnesses presenting written and oral testimony .
Following the hearing , `` the debate at the convention '' on the `` no-aid '' provision `` was extensive , '' she says .
Ellingson notes that `` a number of ministers @ @ @ @ @ @ @ very ardently in favor of public funds not going to religious education . ''
Indeed , Montana argues that the delegates to its 1972 constitutional convention adopted the `` no-aid '' amendment in part `` to protect religious liberty '' and to prevent the state from attaching conditions to its aid .
In the end , the 1972 constitutional redo passed by a vote of 80-to-17 .
During the ratification campaign that followed , Ellingson says , the `` no-aid '' provision was `` never even a threshold issue . ''
And she @ @ @ @ @ @ @ provision specifically allowing private religious schools to receive available federal funds through a state pass-through mechanism .
Ellingson sees Wednesday 's Supreme Court argument in terms of the powers delegated to the states by the federal constitution , including the power of the states to decide how to finance education .
If Espinoza wins , she says , it would mean states no longer `` have the right to determine how public funds are used . ''
In recent years , as the Supreme Court has grown more and more conservative , it @ @ @ @ @ @ @ the notion of a strict wall of separation between church and state , and toward a greater accommodation of religion .
It has , for instance , allowed states to provide vouchers to parents for use in both religious and non-religious private schools .
But there is a difference between allowing and requiring .
This case moves that debate a huge step further , according to Daniel Mach , director of the ACLU Program on Freedom of Religion and Belief .
`` In the past , the court , echoing the framers of @ @ @ @ @ @ @ , '' says Mach .
`` Now the court is actually considering not only allowing but forcing taxpayers to subsidize religious activities . ''
The question in Wednesday 's case , then , is not whether a state may , if it wishes , provide such aid to private religious schools , but whether it must .

Supreme Court Considers Religious Schools Case
Enlarge this image toggle caption Christopher Duperron/Institute for Justice Christopher Duperron/Institute for Justice
The U.S. Supreme Court hears arguments Wednesday in a major case that could dramatically alter the line separating church and state.
At issue is a Montana state constitutional amendment that bars direct and indirect taxpayer aid to religious institutions. Conservative religious groups and advocates of school choice are challenging the "no-aid" provision.
They have long sought to invalidate state constitutional amendments that prohibit taxpayer funding from going to religious schools. Given that Montana is one of 38 states with a "no-aid" provision, the court's eventual decision could have far-reaching consequences.
The case began in 2015 when the Montana Legislature passed a bill providing a dollar-for-dollar tax credit for individuals who donate to organizations that provide scholarship money to students in private schools. An organization called Big Sky began raising money to fund these scholarships, using the tax credit as an incentive. Of the 13 schools that got scholarship money from Big Sky, 12 were religious schools. Indeed, 70% of all private schools in Montana are religiously affiliated.
Ultimately, the Montana Supreme Court struck down the entire tax credit program for all private schools, religious and nonreligious alike. It said the tax credit conflicted with the state constitution, which bars all state aid for religious education, whether direct or indirect, like a tax subsidy.
School choice advocates are now asking the U.S. Supreme Court to revive the scholarship aid program in its entirety. They are backed by the Trump administration, including Education Secretary Betsy DeVos, who as a private citizen and as a Cabinet member has advocated for what she recently called "faith-based education."
Baby Blaine Amendments
Kendra Espinoza, the lead plaintiff in the case, has two daughters attending the Stillwater Christian School in Kalispell, Mont. She is an office manager and staff accountant who works extra jobs to pay for her children's tuition.
"I wanted my kids to have a really strong sense of right and wrong from a biblical perspective," Espinoza said of her decision to send her children to a religious school. "I want them to understand that our sense of ethics and our morals come from God's word, not just man's ideas."
"The only reason" the Montana Supreme Court invalidated the tax program "was because it included religious schools," maintains Erica Smith, a senior attorney at the Institute for Justice, which for decades has been fighting to get rid of state constitutional provisions like the one in Montana.
She argues that the federal Constitution's guarantee of equal protection of the law mandates that the tax credit program be revived and applied equally to all private schools, religious and nonreligious alike. "Once you have these programs," Smith says, "you have to treat families going to religious schools equal to families going to nonreligious schools."
The state of Montana, however, disagrees. It defends the state constitutional provision barring direct or indirect state aid, like tax credits, for religious education.
At the heart of the case are what opponents of these "no-aid" provisions call "baby Blaine Amendments," named after James G. Blaine, who introduced a similar amendment to the federal Constitution in Congress in 1875. While the original Blaine Amendment failed to pass, variations of it were adopted in most states. Many scholars today view the adoption of these amendments, mostly in the late 1800s, as a bigoted reaction to the mass immigration of Catholics into the U.S.
Lawyers for Espinoza argue that the Montana amendment, which was originally adopted in the late 1800s, was "born of" bigotry against Catholics and therefore that the state's "no-aid" provision discriminates against religion in violation of the federal constitution.
Smith notes that these "baby Blaine Amendments" have never been squarely challenged in the Supreme Court before, but she hopes that "the court will take the opportunity to end the bigotry behind these Blaine amendments."
The state constitution
The Montana constitutional amendment, however, is not some relic of the past. Though the no-aid provision was originally adopted in 1889, the state constitution was revised and rewritten in 1972.
All but one of the surviving delegates to that convention have submitted a brief in this case discussing how the "no-aid" provision was debated and enacted 48 years ago.
They dispute Smith's claim that the 1972 convention's "no-aid" provision was just a rubber stamp of the 1889 provision.
"There was clearly some interest being expressed on behalf of the parochial schools to open up the no-aid provision," recalls Mae Nan Ellingson, one of the delegates. She says a daylong hearing was held, with some 100 witnesses presenting written and oral testimony. Following the hearing, "the debate at the convention" on the "no-aid" provision "was extensive," she says.
Ellingson notes that "a number of ministers" who were convention delegates "spoke very ardently in favor of public funds not going to religious education." Indeed, Montana argues that the delegates to its 1972 constitutional convention adopted the "no-aid" amendment in part "to protect religious liberty" and to prevent the state from attaching conditions to its aid.
In the end, the 1972 constitutional redo passed by a vote of 80-17. During the ratification campaign that followed, Ellingson says, the "no-aid" provision was "never even a threshold issue." And she notes that the no-aid measure included a provision specifically allowing private religious schools to receive available federal funds through a state pass-through mechanism.
Ellingson sees Wednesday's Supreme Court argument in terms of the powers delegated to the states by the federal Constitution, including the power of the states to decide how to finance education. If Espinoza wins, she says, it would mean states no longer "have the right to determine how public funds are used."
In recent years, as the Supreme Court has grown more and more conservative, it has moved with increasing vigor away from the notion of a strict wall of separation between church and state and toward a greater accommodation of religion. It has, for instance, allowed states to provide vouchers to parents for use in both religious and nonreligious private schools.
But there is a difference between allowing and requiring. This case moves that debate a huge step further, according to Daniel Mach, director of the ACLU Program on Freedom of Religion and Belief.
"In the past, the court, echoing the framers of the Constitution, guarded against government-funded religion," says Mach. "Now the court is actually considering not only allowing, but forcing taxpayers to subsidize religious activities."
The question in Wednesday's case, then, is not whether a state may, if it wishes, provide such aid to private religious schools, but whether it must.


npr--2020-01-22--Health Officials In China Say 9 Dead From Newly Identified Coronavirus

Health Officials In China Say 9 Dead From Newly Identified Coronavirus Updated at 5:45 a.m .
ET A newly identified strain of coronavirus has killed nine people in China , with 440 other confirmed infections , health officials in Beijing said Wednesday , as they expressed concern over its spread during the Lunar New Year celebrations .
China 's Bureau of Disease Prevention and Control said that while the virus does not appear to be as virulent as the one that caused a Severe Acute Respiratory Syndrome pandemic 17 years ago , it is nonetheless `` highly infectious . ''
@ @ @ @ @ @ @ the respiratory tract , '' Li Bin , deputy director of China 's National Health Commission , which overseas the bureau , said at a Wednesday morning news conference in Beijing .
`` It may mutate and there is risk of further spread . ''
Lunar New Year is China 's – and the world 's – busiest travel season .
Officially , the New Year is this Saturday , but celebrations continue well into February .
About 400 million Chinese are expected to travel within and outside the country beginning at the @ @ @ @ @ @ @ Chinese New Year , the surge [ in people moving around the country ] increases the risk of the epidemic 's spread and the difficulty of prevention and control .
We must not take it lightly , '' Li said , according to a translation in the South China Morning Post .
Li said residents of Hubei province , where Wuhan is located , should avoid densely populated areas and public gatherings .
Earlier , the Disease Prevention Bureau 's chief epidemiologist , Zeng Guang , urged an unofficial quarantine of Wuhan .
@ @ @ @ @ @ @ to Wuhan if possible and that people in Wuhan can stay there , '' he said .
The virus , known as 2019-nCoV , was discovered last month in the central city of Wuhan .
Since then , it has spread to other parts of China , and isolated cases have been found in Japan , Thailand , South Korea , the U.S. and Hong Kong .
Hong Kong confirmed its first case on Wednesday , local broadcasters reported .
Hong Kong 's Cathay Pacific Airways also announced that it would honor a @ @ @ @ @ @ @ allow cabin crew to wear surgical masks on all flights .
Earlier , Cathay had agreed to allow the masks only on flights to mainland China , but said Wednesday in a statement : `` Due to the evolving information from health authorities , we will allow crew members and front-line airport employees to wear surgical face masks when on duty at their discretion . ''
The airline also said it would allow passengers who are booked to and from Wuhan to cancel or reschedule flights for free through Feb. 15 .
On @ @ @ @ @ @ @ Control and Prevention confirmed that a man from Washington state who returned after a trip to Wuhan , China , on Jan. 15 , had sought medical attention days later and is now in isolation at Providence Regional Medical Center in Everett , Wash. State health officials have described his condition as `` healthy . ''
In an interview Wednesday on CNBC , President Trump said he had been briefed about the U.S. case .
`` It 's one person from China and we have it totally under control , '' he said @ @ @ @ @ @ @ it had begun screening passengers arriving from Wuhan at three airports , Los Angeles International , San Francisco International and New York 's JFK .
On Tuesday , the CDC said it was adding Atlanta 's Hartfield-Jackson International and Chicago 's O'Hare International to the list and that all arrivals from Wuhan would be routed through those five airports .
At London 's Heathrow airport , a separate area will be set up to screen passengers from areas affected by the virus , Britain 's Transport Minister Grant Shapps said Wednesday .
The @ @ @ @ @ @ @ uptick in confirmed cases in China was due to more effective diagnosis .
He said 2,197 people who were in close contact with infected patients were being tracked and that 1,394 of them are under close medical observation .
Meanwhile , the head of China 's Bureau of Disease Prevention and Control said Wednesday that the new virus had originated in wild animals sold at a seafood market in Wuhan .
The bureau 's director general , Gao Fu , referred to a paper published on Tuesday by a joint team of researchers @ @ @ @ @ @ @ the People 's Liberation Army and the Institut Pasteur in Shanghai that concluded `` the Wuhan coronavirus ' natural host could be bats ... but between bats and humans there could be an unknown intermediate . ''
The new virus and the SARS virus are both mutations of HKU9-1 , a virus found in fruit bats , the researchers said , according to the South China Morning Post .
Previously , most scientists had believed that the Wuhan virus could not cause a SARS-like epidemic because the two viruses were genetically dissimilar .
@ @ @ @ @ @ @ that the new virus , `` although comparatively weaker '' than SARS , binds to the same human enzyme that has been identified as the receptor for the SARS virus .
An animal-to-human transmission of the SARS virus – which originated in China and was spread across the globe by infected air passengers beginning in late 2002 and continuing into 2003 – has long been suspected , with bats a prime suspect , according to the World Health Organization .
During the 2002-2003 pandemic , SARS infected more than 8,000 people , with @ @ @ @ @ @ @ Europe and North America , including nine in the U.S .
The disease caused 774 deaths , mostly in mainland China , Hong Kong and Taiwan , according to the CDC .

Newly Identified Coronavirus Has Killed 17 People, Chinese Health Officials Say
Enlarge this image toggle caption Dake Kang/AP Dake Kang/AP
Updated at 5:35 p.m. ET
A newly identified strain of coronavirus has killed at least 17 people in China and caused hundreds of confirmed infections, the Hubei provincial government said Wednesday, citing the latest figures from hard-hit Wuhan and other cities.
Health officials in Beijing say they're concerned that the deadly coronavirus could spread further during the Lunar New Year celebrations. Chinese state media reports that Wuhan authorities will temporarily suspend bus, subway, ferry and long-distance passenger transport, and cancel flights and trains, in an attempt to help contain the virus.
There were 555 confirmed cases of the virus, mostly in China, as of Wednesday evening, according to according to a dashboard tracker created by Johns Hopkins University.
A few coronavirus cases have been reported outside China, but no deaths have been reported outside the country.
China's Bureau of Disease Prevention and Control said that while the virus does not appear to be as virulent as the one that caused a SARS — severe acute respiratory syndrome — pandemic 17 years ago, it is nonetheless "highly infectious."
"The virus is mainly transmitted through the respiratory tract," Li Bin, vice minister of China's National Health Commission, which overseas the bureau, said at a Wednesday news conference of a health expert panel in Beijing. "It may mutate and there is risk of further spread."
"We have ensured management of export channels such as temperature checks at airports, train and bus stations, and ports ... And we will reduce as much as possible events with large crowds," Li said.
Enlarge this image toggle caption Mark Schiefelbein/AP Mark Schiefelbein/AP
Lunar New Year is China's — and the world's — busiest travel season. Officially, the holiday is this Saturday, but celebrations continue well into February. About 400 million Chinese are expected to travel within and outside the country beginning at the end of the week.
"During Chinese New Year, the surge [in people moving around the country] increases the risk of the epidemic's spread and the difficulty of prevention and control. We must not take it lightly," Li said.
He said residents of Hubei province, where Wuhan is located, should avoid densely populated areas and public gatherings.
The virus, known as 2019-nCoV, was discovered last month in the central city of Wuhan. Since then, it has spread to other parts of China, and isolated cases have been found in Japan, Thailand, South Korea, the U.S. and Hong Kong.
Symptoms of infection include fever, dry cough, difficulty breathing, diarrhea and body aches.
On Monday, Chinese state media reported that 15 health workers treating patients had also become infected with the virus, including one of the country's most preeminent respiratory doctors, suggesting human-to-human transmission of the virus, although Chinese health authorities have yet to confirm that.
Hong Kong discovered its first case on Wednesday, local broadcasters reported. The financial hub's flagship carrier, Cathay Pacific Airways, also announced that it would honor a request from the flight attendants union to allow cabin crew to wear surgical masks on all flights.
Earlier, Cathay had agreed to allow the masks only on flights to mainland China, but said Wednesday in a statement: "Due to the evolving information from health authorities, we will allow crew members and front-line airport employees to wear surgical face masks when on duty at their discretion."
The airline also said it would allow passengers who are booked to and from Wuhan to cancel or reschedule flights for free through Feb. 15.
On Tuesday, the U.S. Centers for Disease Control and Prevention confirmed that a man from Washington state who returned after a trip to Wuhan, China, on Jan. 15 had sought medical attention days later and is now in isolation at Providence Regional Medical Center in Everett, Wash. State health officials have described his condition as "healthy."
In an interview Wednesday on CNBC, President Trump said he had been briefed about the U.S. case. "It's one person from China and we have it totally under control," he said.
The CDC announced last week that it had begun screening passengers arriving from Wuhan at three airports, Los Angeles International, San Francisco International and New York's JFK. On Tuesday, the CDC said it was adding Atlanta's Hartfield-Jackson International and Chicago's O'Hare International to the list and that all arrivals from Wuhan would be routed through those five airports.
At London's Heathrow airport, a separate area will be set up to screen passengers from areas affected by the virus, Britain's Transport Minister Grant Shapps said Wednesday.
Airports across Asia also say they are screening in-bound passengers from China. Even North Korea has suspended all foreign tourism activities as a precaution.
The sharp rise in the number of cases of the never-before-seen virus has left many in China suspicious that local governments covered up previous cases of the virus. The first case of the Wuhan coronavirus was reported on Dec. 31, with the total number of reported cases breaking 60 only on Saturday.
The Health Commission's Li said the sudden uptick in confirmed cases was due to more effective diagnosis. He said 2,197 people who were in close contact with infected patients were being tracked and that 1,394 of them are under close medical observation.
Meanwhile, Chinese residents emptied shelves of surgical face masks as they geared up for a potential epidemic. Their anxiety stems in part from a history of leaders obscuring the severity of previous outbreaks. Last year, provinces initially hid the full extent of African swine fever, allowing it to spread unchecked for months and decimating China's domestic pork herds. In 2003, China at first denied reports of SARS.
This time, officials are promising that it will be different. "Party committees, governments and relevant departments at all levels should put people's lives and health first," declared China's leader, Xi Jinping, in remarks aired on the country's state broadcaster earlier this week. The central political and legal affairs commission, a ruling political body, warned that anyone found to be covering up cases of the virus would be met with "severe punishment."
The Health Commission has committed to releasing an updated count of all confirmed and suspected cases in daily briefings and on its website, according to Xu Shuqiang, director-general of the agency's emergency response office.
The head of China's Bureau of Disease Prevention and Control said Wednesday that the new virus originated in wild animals sold at a seafood market in Wuhan, similar to the way scientists believe SARS made the leap to humans in 2002.
The bureau's director general, Gao Fu, referred to a paper published on Tuesday by a joint team of researchers from the Chinese Academy of Sciences, the People's Liberation Army and the Institut Pasteur in Shanghai that concluded "the Wuhan coronavirus' natural host could be bats ... but between bats and humans there could be an unknown intermediate."
The new virus and the SARS virus are both mutations of HKU9-1, a virus found in fruit bats, the researchers said, according to the South China Morning Post.
Previously, most scientists had believed that the Wuhan virus could not cause a SARS-like epidemic because the two viruses were genetically dissimilar.
The new study, however, concludes that the new virus, "although comparatively weaker" than SARS, binds to the same human enzyme that has been identified as the receptor for the SARS virus.
An animal-to-human transmission of the SARS virus – which originated in China and was spread across the globe by infected air passengers beginning in late 2002 and continuing into 2003 – has long been suspected, with bats a prime suspect, according to the World Health Organization.
An expert panel convened by WHO on Wednesday said that more evidence is needed before it can decide whether the outbreak meets conditions for an international public health emergency. The panel has requested more information from Chinese authorities on how the virus is transmitting and will meet again on Thursday to review the data.
During the 2002-2003 pandemic, SARS infected more than 8,000 people, with several cases in other Asian countries, Europe and North America, including nine in the U.S. The disease caused 774 deaths, mostly in mainland China, Hong Kong and Taiwan, according to the CDC.


npr--2020-01-22--Gallup Poll: Dissatisfaction With U.S. Abortion Laws On The Rise

Gallup Poll : Dissatisfaction With U.S .
Abortion Laws On The Rise A new Gallup poll finds a record number of Americans are unhappy with the nation 's abortion laws — a shift mostly caused by growing dissatisfaction among Democrats .
`` This is almost entirely driven my Democrats and Independents who lean Democratic , '' said Lydia Saad , Gallup 's director of U.S Social Research .
`` So that underlying trend is very clear , and it 's showing up in the attitudes among all Americans . ''
The poll finds 58 % of Americans are dissatisfied with @ @ @ @ @ @ @ satisfied — a new low since Gallup began tracking this data in 2001 .
In the survey , 31 % of Democrats polled during the Trump administration said they want less strict abortion laws ; during the last Republican administration , that of President George W. Bush , 14 % of Democrats held that opinion .
Saad said the shifting attitudes among Democrats could be driven by President Trump 's rhetoric and policies in opposition to abortion rights .
She said it could also be attributable to a trend in many conservative-leaning states @ @ @ @ @ @ @ early in the first trimester , `` so that there is just perhaps much more awareness among Democrats under this presidency than there was in the past of what 's happening at the state level , '' she said .
The poll found that a nearly equal number of Americans say they want stricter laws ( 24 % ) , as compared to those who want less strict abortion laws ( 22 % ) .
Saad said attitudes among Republican-leaning voters — who tend to believe abortion laws should be stricter — have @ @ @ @ @ @ @ survey respondents have expressed a rapidly intensifying displeasure with the nation 's abortion policies , which they see as too strict .
`` The one really unique thing that we 're seeing is that Democrats are now saying , 'Hey , wait a minute , ' basically .
Which they have n't said for awhile , '' Saad said .
It 's not clear how that shift in opinion could affect voting .
Saad said Gallup 's latest survey looking specifically at how issues shape voting did not find any noticeable uptick among @ @ @ @ @ @ @ concern .
`` It 's possible Democrats right now are thinking in terms of the primaries , and so it 's not a big factor ... but when they turn to thinking about the general election , they will be factoring in the abortion issue more than they might have been in the last election , '' Saad said .
Gallup conducted the poll of 1,014 U.S. adults ages 18 and older during the first half of January .
The margin of error was +/- 4 percentage points .

Gallup Poll: Dissatisfaction With U.S. Abortion Laws On The Rise
Enlarge this image toggle caption Bloomberg/Bloomberg via Getty Images Bloomberg/Bloomberg via Getty Images
A new Gallup poll finds a record number of Americans are unhappy with the nation's abortion laws — a shift mostly caused by growing dissatisfaction among Democrats.
"This is almost entirely driven by Democrats and Independents who lean Democratic," said Lydia Saad, Gallup's director of U.S Social Research. "So that underlying trend is very clear, and it's showing up in the attitudes among all Americans."
The poll finds 58% of Americans are dissatisfied with U.S. abortion laws while 32% are satisfied — a new low since Gallup began tracking this data in 2001.
In the survey, 31% of Democrats polled during the Trump administration said they want less strict abortion laws; during the last Republican administration, that of President George W. Bush, 14% of Democrats held that opinion.
Saad said the shifting attitudes among Democrats could be driven by President Trump's rhetoric and policies in opposition to abortion rights. She said it could also be attributable to a trend in many conservative-leaning states toward passing new abortion restrictions, some early in the first trimester, "so that there is just perhaps much more awareness among Democrats under this presidency than there was in the past of what's happening at the state level," she said.
The poll found that a nearly equal number of Americans say they want stricter laws (24%), as compared to those who want less strict abortion laws (22%).
Saad said attitudes among Republican-leaning voters — who tend to believe abortion laws should be stricter — have remained relatively stable. Meanwhile, Democratic-leaning survey respondents have expressed a rapidly intensifying displeasure with the nation's abortion policies, which they see as too strict.
"The one really unique thing that we're seeing is that Democrats are now saying, 'Hey, wait a minute,' basically. Which they haven't said for awhile," Saad said.
It's not clear how that shift in opinion could affect voting. Saad said Gallup's latest survey looking specifically at how issues shape voting did not find any noticeable uptick among Democrats listing abortion as a major motivating concern.
"It's possible Democrats right now are thinking in terms of the primaries, and so it's not a big factor...but when they turn to thinking about the general election, they will be factoring in the abortion issue more than they might have been in the last election," Saad said.
Gallup conducted the poll of 1,014 U.S. adults ages 18 and older during the first half of January. The margin of error was +/- 4 percentage points.


npr--2020-01-21--Supreme Court Allows Flint Water Lawsuits To Move Forward, Officials Not 'Immune'

Supreme Court Allows Flint Water Lawsuits To Move Forward , Officials Not 'Immune' The Supreme Court on Tuesday cleared the way for water crisis victims to sue state and local government officials in Flint , Mich. For years , Flint city officials and state regulators have argued that they are protected by `` qualified immunity '' from being sued for their role in the water contamination crisis .
But lower courts have ruled to the contrary .
In refusing to take up a pair of cases involving the lead-tainted water , the Supreme Court has upheld those lower court rulings @ @ @ @ @ @ @ on the class action lawsuit , which includes thousands of Flint residents suing for damages from the 2014 incident , welcomed the decision as a major victory .
He said , `` It 's time for the people of Flint to start feeling like they are going to get their day in court , '' Michigan Radio reporter Steve Carmody reported .
`` This just moves the entire process closer to that day . ''
Pitt added that his clients have thus far `` been denied justice . ''
The initial lawsuit turned @ @ @ @ @ @ @ in 2016 .
It argues that officials , including then-Gov .
Rick Snyder , acted indifferently to the risk of bodily harm that residents faced when they were exposed to high levels of lead and other contaminants after the city 's drinking water source was switched to draw from the Flint River in 2014 .
The move was made without properly treating pipes for corrosion , letting lead and bacteria into the water supply .
In an April 2019 ruling , U.S. District Judge Judith Levy ruled that Snyder `` was indifferent because @ @ @ @ @ @ @ caused by the contaminated water , he covered it up .
In private , he worried about the need to return Flint to [ Detroit 's water system ] and the political implications of the crisis .
But in public , he denied all knowledge , despite being aware of the developing crisis .
As a result , plaintiffs were lured into a false sense of security . ''
More than a year later , the city switched to using water from Lake Huron .
But that came too late to prevent a @ @ @ @ @ @ @ Flint 's tap water came from the Flint River , a Legionnaires disease outbreak occurred , killing at least 12 people .
Dozens of others were hospitalized .
Although government officials initially claimed the water was safe to drink , 18 months later they admitted it was not .
It was n't until late 2016 that the city 's water supply finally met federal safety standards , though some residents remain skeptical of those findings .
Defense attorney Pitt says it could be another year before an actual trial begins .
The events @ @ @ @ @ @ @ cities to remove aging lead water pipes .
As Tom Neltner at the Environmental Defense Fund told WBEZ 's Monica Eng , `` Our country has an estimated 6 million lead service lines .
... And it 's like drinking water through a lead straw .
So where people have them , it 's one of the most significant sources of lead in drinking water . ''
About 180 cities and towns across the country are taking action to remove harmful pipes .
In Flint , crews have been working to replace old @ @ @ @ @ @ @ pipes .

Supreme Court Allows Flint Water Lawsuits To Move Forward, Officials Not 'Immune'
Enlarge this image toggle caption Carolyn Kaster/AP Carolyn Kaster/AP
The Supreme Court on Tuesday cleared the way for water crisis victims to sue state and local government officials in Flint, Mich.
For years, Flint city officials and state regulators have argued that they are protected by "qualified immunity" from being sued for their role in the water contamination crisis. But lower courts have ruled to the contrary.
In refusing to take up a pair of cases involving the lead-tainted water, the Supreme Court has upheld those lower court rulings.
Attorney Michael Pitt, co-lead counsel on the class action lawsuit, which includes thousands of Flint residents suing for damages from the 2014 incident, welcomed the decision as a major victory.
He said, "It's time for the people of Flint to start feeling like they are going to get their day in court," Michigan Radio reporter Steve Carmody reported. "This just moves the entire process closer to that day."
Pitt added that his clients have thus far "been denied justice."
The initial lawsuit turned away by the high court was filed in 2016. It argues that officials, including then-Gov. Rick Snyder, acted indifferently to the risk of bodily harm that residents faced when they were exposed to high levels of lead and other contaminants after the city's drinking water source was switched to draw from the Flint River in 2014. The move was made without properly treating pipes for corrosion, letting lead and bacteria into the water supply.
In an April 2019 ruling, U.S. District Judge Judith Levy ruled that Snyder "was indifferent because instead of mitigating the risk of harm caused by the contaminated water, he covered it up. In private, he worried about the need to return Flint to [Detroit's water system] and the political implications of the crisis. But in public, he denied all knowledge, despite being aware of the developing crisis. As a result, plaintiffs were lured into a false sense of security."
More than a year later, the city switched to using water from Lake Huron. But that came too late to prevent a dozen fatalities.
During the period that Flint's tap water came from the Flint River, a Legionnaires disease outbreak occurred, killing at least 12 people. Dozens of others were hospitalized.
Although government officials initially claimed the water was safe to drink, 18 months later they admitted it was not.
It wasn't until late 2016 that the city's water supply finally met federal safety standards, though some residents remain skeptical of those findings.
Defense attorney Pitt says it could be another year before an actual trial begins.
The events in Flint have triggered scores of Midwest cities to remove aging lead water pipes.
As Tom Neltner at the Environmental Defense Fund told WBEZ's Monica Eng, "Our country has an estimated 6 million lead service lines. ... And it's like drinking water through a lead straw. So where people have them, it's one of the most significant sources of lead in drinking water."
About 180 cities and towns across the country are taking action to remove harmful pipes.
In Flint, crews have been working to replace old lead and galvanized service lines with copper pipes.