KEOKUK, Iowa — Folks in this Mississippi River town hope a new federal program can revive the optimism engraved long ago in a plaque on the side of their hospital.

“Dedicated to the Future of Health Care in the Tri-State Area,” the sign declares. “May 11, 1981.”

More recent placards posted at the facility’s entryways are ominous, however. “Closed,” they say. “No Trespassing.”

The Keokuk hospital, which served rural areas of Iowa, Illinois, and Missouri, closed in October 2022. But new owners plan to reopen the hospital with the help of a new federal payment system. The Rural Emergency Hospital program guarantees hospitals extra cash if they provide emergency and outpatient services but end inpatient care.

“We’ve been without a hospital for over a year — and I don’t think anybody in Keokuk or the surrounding areas will be picky in any way, shape, or form,” said Kathie Mahoney, mayor of the town of about 9,800 people. She said residents would prefer to have a full-service hospital with inpatient beds, even though those types of beds had been used sparingly in recent years.

The revival of the Keokuk hospital would mark a small victory in the nationwide struggle to save rural hospitals, which continue to close due to staffing shortages, low reimbursement rates, and declining patient numbers. The new federal program, which went into effect in January 2023, is meant to stem the closures. But there have been growing pains, said George Pink, deputy director of the North Carolina Rural Health Research Program, which tracks hospital closures and conversions.

Just 18 of the more than 1,700 eligible rural hospitals nationwide have applied for and won the new designation. Many hospitals are reluctant to give up inpatient services entirely, and some are concerned about how other payment streams could be affected, rural health leaders say. The new designation’s unclear definition of “rural” has also caused confusion.

“We are still in an era of rural hospital closures,” Pink said. Nine hospitals closed in 2023, and that number could rise in 2024, he said. An influx of federal relief funds during the pandemic kept struggling hospitals afloat, but now that money is largely gone.

The Rural Emergency Hospital program is the first new federal payment model for hospitals since 1997. Dora Hughes, acting chief medical officer of the Centers for Medicare & Medicaid Services, said the new model’s criteria are outlined by statute and “hospitals should consider specific circumstances before making the decision to apply.”

The federal agency is providing outreach to rural communities and welcomes feedback, Hughes wrote in an email to KFF Health News.

Now, rural health leaders and federal lawmakers are working quickly to tweak the new program to attract more applicants, said Carrie Cochran-McClain, chief policy officer of the National Rural Health Association.

Currently, facilities that convert to rural emergency hospitals receive a 5% increase in Medicare payments, plus an average annual payment of about $3.2 million, in exchange for giving up their expensive inpatient beds and focusing solely on emergency and outpatient care. Rural hospitals with no more than 50 beds, like Keokuk’s, that closed after the law was signed on Dec. 27, 2020, are eligible to apply for the program and reopen with emergency and outpatient services.

More than 100 rural hospitals nationwide have inquired about converting, said Janice Walters, interim executive director for the Rural Health Redesign Center, which has a federal grant to provide technical assistance to hospitals that want to apply.

But only about a quarter of those inquiries are likely to become a rural emergency hospital, and persuading more troubled hospitals to make the leap would require regulators to make changes, Walters said.

Her advice? “Give them 10 beds to just take care of their community.”

In a journal article published last year, general surgeon Sara Schaefer worried about the unintended consequences of getting rid of rural inpatient beds. Schaefer, who spent six months of medical school at a small rural Idaho hospital, said she saw firsthand how difficult it was for the hospital to transfer patients to bigger facilities, which were often too full to take them.

“There has to be a better way,” said Schaefer, who is also a research fellow at the Center for Healthcare Outcomes & Policy at the University of Michigan.

The rural health association’s Cochran-McClain said lawmakers are considering changes that could allow the hospitals to:

• Keep overnight beds for patients who need moderate levels of care, such as those with pneumonia or in need of physical therapy after surgery.
• Allow participation in a federal drug discount program called 340B, which provides hospitals with extra revenue.
• Keep inpatient psychiatric or rehabilitation units open.
• Clarify eligibility, including which facilities qualify under the definition of “rural” and whether the hospitals that closed before the 2020 date in the law can apply.

Updates to the law could affect communities nationwide. In Fort Scott, Kansas, where the hospital closed in late 2018, Mayor Matthew Wells said the community wants the eligibility date pushed back. U.S. Sen. Jerry Moran (R-Kan.) introduced a bill in December that, if passed, would push eligibility back to 2015.

“This is a matter of life and death to my community,” Wells said. “I see a clear path, but the federal regulations in particular make that path nearly impossible.”

In Holly Springs, Mississippi, hospital chief executive Kenneth Williams said he doesn’t understand the federal definition of “rural.” His hospital, Alliance Healthcare Hospital, was one of the first to win the new Rural Emergency Hospital designation in early 2023. He laid off staff and shut down his inpatient beds. Then, CMS officials called to tell him they had made a mistake.

“And I said, ‘Wait a minute,’” Williams said. The hospital, which is about an hour south of Memphis, Tennessee, doesn’t meet the current criteria of rural, they told him. Williams, an internal medicine doctor, bought the hospital in 1999 and has been trying to keep it running since.

Federal regulators are now asking Williams to convert the facility into another type of Medicare payment model, such as the sole community hospital with inpatient beds that it was before. Williams said that would be difficult: “What kind of transition can I make, especially with reduced services?”

In Keokuk, the hospital fits the current requirements. Insight Health Group, the Michigan company that bought the shuttered facility last March, plans to apply for the new federal designation as soon as it obtains state permits under new Iowa regulations tailored to rural emergency hospitals. It would be the first such hospital in the state.

Like many other rural hospitals struggling to survive, Keokuk’s shuttered several key departments years ago, including its birthing and inpatient psychiatric units. In 2021, the last full year it was open, the hospital averaged fewer than three inpatients per night, according to data posted by the Iowa Hospital Association.

More than half of the three-story building would remain mothballed if the facility reopened under the new designation, but the emergency department could serve patients again as soon as late summer, said Atif Bawahab, Insight’s chief strategy officer.

Bruce Mackie has worked 32 years at the hospital, including 10 years as director of plant operations. The new owners kept him on to watch over the building. Beds, high-tech scanners, and lab equipment remain, but most of the clocks have stopped. “It’s spooky,” he said.

Even if the services are more limited than before, Mackie said, “everybody wants the hospital to reopen. This city needs an ER.”

(KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs of KFF — the independent source for health policy research, polling and journalism.)

©2024 KFF Health News. Distributed by Tribune Content Agency, LLC.

When 17 nursing homes closed in Ohio in fiscal 2023, the Ohio Health Care Association, which represents nursing homes in the state, echoed a refrain often used by the industry to explain closures and get more funding from the state: Medicaid reimbursement rates are too low and it is too hard to find staff.

It’s the same argument that the industry has made on a national scale for decades, but particularly since the COVID-19 pandemic, which saw thousands of residents die while facilities faced increased labor and supply costs.

While staffing and reimbursement issues have certainly contributed to closures in some cases, especially for smaller, rural facilities, experts say the debate often omits some important facts and nuance: specifically, that many facilities that close are poor quality, have high staff turnover and are located in areas where multiple other homes and alternatives exist, making it difficult to fill empty beds. Others turn into assisted living facilities, which are more loosely regulated. A handful were kicked off of the Medicare program for low quality.

“I think that’s one of the most powerful arguments that the industry has used to scare policymakers and senators and other decision-makers, and it’s really disconnected if you think about it,” said Sam Brooks, director of public policy for the National Consumer Voice for Quality Long-Term Care. “When you actually look at the data, and you look at the homes closing, it’s really because they’re just bad homes providing bad care, and they can’t fill their beds so they’re just closing down.”

Yet, the industry continues to demand more funding from taxpayers. They’ve also used the closures to try to fend off a controversial Biden administration rule that would mandate minimum staffing levels in nursing homes, a standard that currently does not exist.

“We believe that if the Biden staffing mandate is finalized, that it will accelerate the closures of buildings,” said Mark Parkinson, president and CEO of the American Health Care Association, which represents the interests of the nation’s nursing homes.

“Very good nursing homes are closing because they can’t find workers and the reimbursement isn’t enough. And for people to just be out there making these subjective statements that it’s just poor buildings that are closing, it’s just not accurate. It leads policymakers to potentially make poor decisions, and it has real impacts on people’s lives,” Parkinson said.

A changing industry

There are about 15,000 nursing homes in the U.S., and dozens close every year. While experts believe there was likely an uptick in closures during the pandemic, experts think COVID-19 aid to the industry likely prevented more facilities from closing.

Nursing homes have long struggled to recruit and retain staff, largely because of low pay, and understaffing generally leads to poorer health outcomes. The industry has blamed low staffing on Medicaid rates, which are set by states.

And when nursing homes close, that is also blamed on reimbursement rates and workforce shortages.

But the truth is more complicated, experts say.

“In general, the lowest-quality care facilities are the ones that end up closing because they just have lower census,” meaning fewer residents. In those cases, facilities bring in less money, said Robert Applebaum, who studies nursing home closures and quality as part of his role as director of the Ohio Long-Term Care Research Project.

Once a nursing home has a low census or not enough staffing, it can become a spiral that can be difficult to get out of, he said.

“It is a bit of a chicken and egg problem,” he said. “Some are low quality and that reduces the census and revenue, and the spiral continues. Some experience census problems, and that results in lower revenue and cuts to staffing.”

The explosion of assisted living facilities and services that allow people to receive care in their home has also driven down the demand for nursing home beds, Applebaum said.

“It’s primarily a natural evolution of a changing industry,” he said.

There are still nearly 1,000 nursing homes in Ohio. The state’s facilities that shuttered in fiscal 2023 had an average occupancy rate of 60 percent, a rate that would make it nearly impossible to be profitable. Four of the 17 closed Ohio facilities were in the federal government’s special focus program or candidates for the program, which puts poor-performing facilities under extra scrutiny.

Seven had health inspection ratings of one star — the lowest possible rating, which takes into account surveys in a three-year period.

While Medicaid rates do likely play a role, particularly for rural and independently owned facilities, it is unclear how much. It’s infamously opaque how nursing homes spend Medicaid funds. Experts say facilities cut staffing to the bone to increase profits or channel funding into related-party transactions.

In Texas, nursing homes received increased payments during the pandemic, but that didn’t lead to improvements in quality, said Andrea Earl, associate state director of advocacy and outreach for AARP Texas.

“If we don’t know where the dollars went and there’s no accountability, it is really hard for us to say the reason for Texas closures is that they didn’t get enough reimbursement or money here,” Earl said.

Nationwide trends

In fiscal 2023, 188 nursing homes, also known as skilled nursing facilities, closed in the U.S., according to a CQ Roll Call analysis of government data.

Overall, facilities that closed were more likely to have had severe inspection violations, had racked up fines for providing poor care, were rated poorly by state and federal governments and were on lists for extra monitoring.

Some were facing wrongful death lawsuits or had stopped paying their bills.

While some 40 percent of those closed facilities were four or five star facilities, 31 percent of closed facilities were one star or part of the special focus facility program, compared with 23 percent of facilities overall.

The star rating system, created by the Centers for Medicare and Medicaid Services, is intended to help consumers identify poor and high-quality nursing homes; facilities with five stars are considered to be of the highest quality. But the rating system has faced scrutiny. Experts say it is easy for facilities to game the system to get higher ratings.

The sector also is graded on a curve, meaning the lowest 20 percent of nursing homes in a state are considered one star, middle-performing facilities receive three stars and the highest performing facilities in a state receive five stars.

Other metrics that nursing homes are graded on can be more useful to look at, experts say, like results of health inspections, which are unannounced.

Half of the facilities that closed in fiscal 2023 had received code J or higher deficiencies — which indicate serious immediate jeopardy to resident health and safety — compared with 11 percent of facilities overall, according to government data.

Ten percent of facilities that closed in fiscal 2023 had been cited for abuse, compared with 6 percent of facilities overall, while 13 percent of closed facilities were participants in or candidates for the special focus program, compared with 3.5 percent of facilities overall.

One of the most powerful tools CMS has to enforce nursing home regulations is Medicare payment denials. That tool is typically used as a last resort when facilities have otherwise failed to fix deficiencies.

Twenty-two percent of facilities that closed in fiscal 2023 had received at least one payment denial, compared with 13 percent overall.

Kelly Hughes, a research economist at RTI International, said despite the narrative that more nursing homes are closing, “the situation is not as dire as you’d think if you look at the data.”

The data shows there have been no persistent increases in closure rates from 2011 through 2019, although there were increases in 2018 and 2019, Hughes said.

“We’re having less closures than we did a decade ago,” she said.

The number of new facilities that open every year typically offsets the closures, Hughes said, though the impacts of the pandemic on closures are still unclear.

“The goal is not to have zero closures. There’s always going to be supply and demand. There’s going to be some facilities going out of business for reasons like poor quality or oversupply, and there’s also a lot of facilities entering [the market],” Hughes said.

More problematic, said David Grabowski, professor of health care policy at Harvard Medical School, is “when it’s a high-quality facility in a more rural area without any other options.”

Of the 188 nursing homes that closed in fiscal 2023, about 47 percent were in counties defined as rural by the Federal Office of Rural Health Policy.

Efforts to shore up nursing homes should be targeted at those that need it, especially in rural communities, Grabowski said.

“When it’s a closure in a more densely populated area of a lower-quality facility, that is actually good for the health of the residents,” he said.

___

©2024 CQ-Roll Call, Inc. Visit at rollcall.com. Distributed by Tribune Content Agency, LLC.

With two casino-resort openings and a Major League Baseball team announcing plans to relocate to Las Vegas in 2023, the new year has some big shoes to fill. But there are many significant projects in the early stages that could move forward in 2024. And, of course, we all want to know if projects such as the Atari Hotel will really happen.

Here are some key projects to watch across the valley in 2024.

Dream Las Vegas

Dream Las Vegas is a 531-room boutique hotel proposed for Las Vegas Boulevard just south of the Pinball Hall of Fame. The project’s construction was stopped in early 2023 because of financing issues, but in October developer, Shopoff Realty Investments, said it was working on a new loan to finance the project and construction could resume in early 2024. As of publication, no building permits have been issued and no new documents have been filed with Clark County on Dream Las Vegas and its financing.

Bill Shopoff, president and CEO of Shopoff Realty Investments, recently told the Las Vegas Review-Journal via text message that the loan commitment has been reached for the project and the new financing should close in February. He said construction should resume by the end of March.

Tilman Fertitta-backed Strip casino-resort

Signs of construction on the 43-story casino-resort project backed by billionaire Tilman Fertitta could begin to show this year. The project is proposed for the southeast corner of Las Vegas Boulevard and Harmon Avenue and building permits were first applied for in March.

A Fertitta spokesperson said via email that there aren’t any new updates to share about the resort right now. Plans for the project include 2,420 hotel rooms, restaurants, convention space, spa, wedding chapel and a 2,500-seat theater.

Atari Hotel

Las Vegas was slated to be the first location for a chain of Atari-branded hotels, when renderings were unveiled in 2020.

The developer behind the concept, GSD Group, was looking to develop a 400-room Atari Hotel on a 5-to 7-acre site near the Strip. The target opening date was the end of 2022, which, of course, didn’t happen. Since the renderings were released, there’s been very little news on the project. It’s unclear if development on this project is still happening.

Atari Hotels and Atari didn’t respond to requests for comment. The website for the project remains live.

Casino Royale redevelopment

The Best Western Plus Casino Royale on the Strip could be redeveloped. An aeronautical study was requested from the Federal Aviation Administration to determine how tall of a tower could be constructed on the Strip, between Harrah’s and the Venetian. The study, issued last year, said a building up to 699 feet tall could be built on the site.

No development plans for the site have been submitted to Clark County as of publication. The owner of the hotel didn’t respond to a request for comment.

The Mirage’s closure

The Mirage’s days on the Strip are numbered, but exact details on when it will transition over to the Hard Rock haven’t been disclosed yet.

The Seminole Indian Tribe — owner of the Hard Rock International brand — purchased the property in December 2022. Plans are to transition the property into a Hard Rock branded-resort with a giant 660-foot guitar-shaped hotel tower. But details of the development timeline for this project are still being developed and Hard Rock declined to say how long the property will continue to operate as the Mirage.

Hard Rock CEO Jim Allen said in May that he hoped the redeveloped property could open around the end of 2027 or the start of 2028.

Demolition of the Tropicana, to make way for MLB stadium

Demolitions and implosions have been key to the history of the Las Vegas Strip and it looks like 2024 could be the last year for the Tropicana, one of the few remaining mob-era resorts on the Strip.

The Tropicana opened in April 1957 and could close in 2024 as redevelopment plans call for the property to be demolished to make way for a $1.5 billion, 33,000-seat baseball stadium for the Athletics. The team is set to move from Oakland to Las Vegas after it won a relocation vote by MLB owners in November.

At the time of the owners’ vote, it was reported that construction on the new baseball stadium could start in 2025 and be completed in 2028.

The owner of the Tropicana, Bally’s Corp., didn’t respond to a request for comment on if a demolition or development timeline has been set.

Midtown mixed-use project

Construction could move forward on Midtown, a proposed mixed-used development looking to bring more urban living options to the area around Downtown Las Vegas and the Arts District. Developer Z Life Co. wants to add 3,000 residential units and 100,000 square feet of commercial space to the area surrounding the English Hotel, which it also developed.

The first two buildings of the Midtown project will have 281 residential units and could be open by mid-2025.

Z Life Co. expects to demolish the existing buildings on the site sometime this summer and have an official groundbreaking later in the year, said Anna Olin, chief operating officer and co-founder Z Life Co. She also said reservations for the residential units should open at the end of January.

Wynn Resort’s third tower

Wynn Resorts has owned a 38-acre parcel just north of Fashion Show mall and across Las Vegas Boulevard from the main Strip resort for almost seven years. It inherited development plans for a 1,100 room casino-resort from the previous owner.

A Wynn spokesperson said via email that there are no “immediate” plans to develop the parcel. But Wynn recently applied for a five-year extension of those approval development plans.

The Clark County Building Department staff recommended denying the extension request since the original approval is eight years old and some regulations have changed since then.

BLVD retail center

More flagship retail and restaurant operations on the Strip could be announced in 2024 as the 400,000-square-foot retail center called BLVD is scheduled to finish shell construction in August and open to the public in early 2025.

The developers hope BLVD will attract some high-end brands that don’t already have a retail presence in the U.S. The first two levels of the project will focus on retail and experiential spaces. The top floor will include a 110,000-square-foot dining terrace.

Some early lease announcements for BLVD include large spaces for Adidas, Puma and H&M.

The project is being developed on the site of the former Hawaiian Marketplace.

Westside resort, formerly Harlem Nights

The Las Vegas City Council could rule on a project that would place a high-rise resort in Historic Westside in 2024.

The Westside project, formerly called Harlem Nights, has gone through several iterations since it was first proposed in April. The original Harlem Nights proposal called for a 60-story tower with hotel and residential units. The project has since been scaled back and is currently proposed to be 34 stories. More changes could come, though, as the project still hasn’t gone in front of council.

A spokesperson for the developer, Shlomo Meiri, said there’s still a desire to get the resort built as it could act as an economic catalyst for the Historic Westside. But city staff has recommended denying the project, saying the tower structure wouldn’t be in character for the Historic Westside.

It’s unclear when this project will be considered by city council as it was tabled at a Las Vegas Planning Commission meeting in early January.

Casino-resort above Fashion Show mall

Howard Hughes Holdings floated the idea in October to build a casino-resort above Fashion Show mall. The real estate development company along with Brookfield Properties, which owns Fashion Show, holds the air rights above the mall.

Howard Hughes and Brookfield Properties haven’t elaborated on how or when a resort could be developed in the airspace above Fashion Show, so it’s unclear when or if the project could come to fruition. No plans for the project have been submitted to Clark County at time of publication.

Former Station Casinos sites to be redeveloped

Redevelopment of two properties that house now-shuttered Station Casinos resorts could start taking shape this year.

In November, Station Casinos sold the 73-acre site of the former Texas Station and Fiesta Rancho in North Las Vegas for $59 million to Agora Realty & Management.

Hylo Park, a $380 million three-phased project including a hotel, outdoor recreational space, retail, restaurants, a remodeled hockey facility and 665 residential units, is proposed for the site. Construction on the project should start in August, an Agora Realty spokesperson said.

In December 2022, Station Casinos sold the 35-acre Fiesta Henderson site to the city of Henderson for $32 million. Henderson is planning on adding an indoor sports facility to this site and possibly some hospitality space as well as spaces for family entertainment and open space for the public.

Henderson recently announced it wants to pick a developer for this project by April.

Redevelopment of shuttered Diamond Inn Motel

The now-closed Diamond Inn Motel and its pink elephant are set to go up for auction in March.

A spokesperson for J.P. King Auction Company said bidding for the site should start on March 7 and close on March 14.

The 1.36-acre property is prime for redevelopment because of its location on the Strip across from the Mandalay Bay.

The property could be suited for high-rise luxury condos or an entertainment venue since it can have building heights ranging from 406 to 505 feet tall, according to the auction listing.

Once it sells, it’s unclear how soon the new owner will proceed with redevelopment plans. The big question is, what will happen to the pink elephant?

©2024 Las Vegas Review-Journal. Visit reviewjournal.com.. Distributed by Tribune Content Agency, LLC.

Within two years, a new federal rule will force oil- and gas-producing states to crack down on methane gas emissions — a major driver of climate change.

A handful of states already have rules that force drillers to increase monitoring and upgrade equipment, which advocates say provided an effective template for the federal action.

But many other states will be starting from scratch. In those states, some officials and oil industry leaders say the burden on regulators and fossil fuel producers may outweigh the benefits of reduced emissions.

“Is creating more paperwork going to have the effect the EPA hopes it will have in reducing methane?” said Matthew Bingert, manager of the oil and gas program in North Dakota’s Division of Air Quality.

While carbon dioxide is emitted in far higher quantities, methane is a much more potent greenhouse gas — making it responsible for more than a quarter of the warming that the planet is currently experiencing. It also breaks down much faster in the atmosphere, meaning reducing methane emissions can have a more immediate impact than reducing carbon dioxide, which lingers for longer.

“That makes it a huge opportunity,” said Jon Goldstein, senior director of regulatory and legislative affairs with the Environmental Defense Fund, a legal advocacy group. “If we can get after those emissions quickly, we can start to bend the curve on the climate problem quickly.”

Oil and gas operations are the largest industrial emitter of methane. The U.S. Environmental Protection Agency estimates that its new rule will prevent 58 million tons of methane emissions by 2038 — equivalent to the carbon emissions produced by the entire power sector in 2021.

Federal officials say the rule also will limit toxic pollutants that affect human health in the neighborhoods surrounding drilling operations and refineries.

While some Democratic-led states have gotten a head start on methane regulations, other oil-producing states, many under GOP control, say the new requirements are going to require massive amounts of data collection and analysis for both companies and regulators — and it’s unclear how that work will be funded.

Attorneys general from 24 states sent a letter to the EPA last year saying the rule would impose excess costs on industry and overstep the agency’s authority.

Last month, the federal agency published a final rule giving state agencies two years to draft plans that include regular industry monitoring for leaks at oil and gas operations. The rule also mandates new technologies that limit emissions and venting or “flaring” — burning off — of methane.

With the expansion of their Clean Air Act responsibilities, state agencies without existing methane programs say they’ll likely need to add more staff, which would be funded by taxpayers or additional fees on the oil and gas industry.

The EPA did not make officials available for an interview. Law experts told ALM, a legal publication, that the rule is likely to face challenges in court.

State action

Climate advocates say the federal agency was spurred to act by the success of state-level methane rules, starting with regulations in Colorado in 2014. Over nearly a decade, Colorado has passed a series of rules to increase methane emissions monitoring, require infrastructure upgrades and crack down on flaring.

“Colorado has formed the basis for many of the EPA rules,” said David McCabe, senior scientist with the Clean Air Task Force, a Boston-based environmental advocacy group.

State officials in Colorado denied a Stateline interview request, but oil and gas operators in the state say they’ve been able to meet the state’s requirements.

“We produce some of the cleanest energy molecules in the world,” said Christy Woodward, senior director of regulatory affairs with the Colorado Oil & Gas Association, a trade group. “We’re not only on target to meet [Colorado’s emissions reduction targets] but exceed them.”

Some environmental advocates have a more mixed response. They praise both the Colorado and EPA rules requiring oil and gas drillers to upgrade to equipment that produces fewer leaks, along with strict rules on venting and flaring. But both programs rely on operators — rather than state inspectors — to monitor their own emissions and report leaks.

“There’s not a lot of oversight to ensure that every operator is doing what they’re claiming they’re doing,” said Andrew Klooster, Colorado field advocate with the nonprofit advocacy group Earthworks, which conducts its own inspections with imaging devices that can detect leaks.

Klooster noted that the rules, even with few state-run inspections, give watchdogs such as his team a mechanism to look for violations and hold polluters accountable.

Some environmental groups have been pushing the state to hire more staffers to conduct inspections, said Ean Tafoya, Colorado state director with GreenLatinos, an environmental justice organization.

“We know these companies are violating [emissions standards] in their reporting, and we want to see more enforcement,” he said. “We have more to do.”

Despite the concerns, advocates acknowledge the program likely has curtailed emissions. It also has given Colorado a head start toward meeting the new federal standards.

New Mexico regulators also established methane rules in recent years, requiring companies to capture 98% of the gas they produce by 2026. State officials say emissions have decreased since the rules were passed, estimating the current capture rate at around 60%.

“On net, emissions are down, and we have seen significant reductions in routine venting and flaring,” said Dylan Fuge, deputy secretary of New Mexico’s Energy, Minerals and Natural Resources Department. “Operators and the state are going to be well positioned to comply [with the federal rule].”

While the state’s new standards have required significant infrastructure investments from oil and gas operators, state officials say it hasn’t slowed the industry’s expansion.

“Profits are higher than they’ve ever been; production numbers are higher than they’ve ever been,” said Commissioner of Public Lands Stephanie Garcia Richard. “This is the time to increase oversight, when companies can afford it.”

California regulators also have moved to restrict methane emissions from oil and gas operations, with mandates for leak detection, reporting and infrastructure upgrades. The state Air Resources Board did not respond to an interview request. Meanwhile, Pennsylvania last month began its own rulemaking on methane emissions, in anticipation of the EPA action.

Economic concerns

In other oil-producing states, officials say the new rules will pose a challenge. Bingert, of the North Dakota agency, said the federal standards are likely to double the number of wells his agency is obligated to oversee.

“It’s going to be an increased burden on not only industry but on us as a state agency,” he said. “There’s no talk of funding for these new regulations. Obviously more work is going to be going into it, so that’s definitely a concern of ours.”

Bingert said the agency might need to ask state lawmakers for more money to add positions to carry out the federal requirements.

In Wyoming, state officials fear that smaller companies will struggle to make the infrastructure upgrades required by the new rule.

“The cost to implement and the impact to those operations will be significant,” said Tom Kropatsch, supervisor of the Wyoming Oil and Gas Conservation Commission. “It really impacts local communities if those operations go out of business, because the majority of the operators in Wyoming are small operators.”

Industry officials in the state shared the same concern.

“That’s a hard lift for some of these companies that are one or two people that don’t have full regulatory departments,” said Ryan McConnaughey, vice president and director of communications for the Petroleum Association of Wyoming, a trade group. “This is going to force smaller operators to shut down.”

McConnaughey also said the requirements could strain the capacity of the state’s Department of Environmental Quality. The agency, which did not grant Stateline an interview, cited that concern in a letter to the EPA.

“Conducting the compliance inspections, reports, and emissions inventories work commensurate with the requirements of the proposed rule places an overwhelming strain on agency staff and financial resources,” agency Director Todd Parfitt wrote to the EPA.

Stateline is part of States Newsroom, a national nonprofit news organization focused on state policy.

©2024 States Newsroom. Visit at stateline.org. Distributed by Tribune Content Agency, LLC.

The instant Tammy Brady felt the lump in her breast in February 2022, she knew it was cancer. With no known genetic predisposition for breast cancer, she suspects 38 years of working in smoky Atlantic City casinos played a role.

“I was just trying to make a living,” said Brady, 56, a dealer and supervisor at Borgata in that New Jersey resort city. “You don’t think, you know, that you’re going to get sick at your job.”

Some casinos continue to allow indoor smoking even as the share of Americans who smoke fell from about 21% in 2005 to 12% in 2021 and smoking is banned in at least some public spaces in 35 states, the District of Columbia, and U.S. territories. Still, 13 of the 22 states and territories that allow casino gambling permit smoking in at least part of their facilities.

Brady is among the casino employees, anti-smoking advocates, and public health experts who argue it is long past time to snuff out casino exemptions from smoking bans, given the dangers of secondhand smoke. But they’ve faced stiff pushback from some gambling industry leaders, including in Missouri, Louisiana, Kentucky, and New Jersey, who argue that smoking bans drive gamblers away — especially in places where patrons can go instead to a casino in a nearby jurisdiction that allows them to light up.

The COVID-19 pandemic renewed this fight and sharpened the arguments on both sides — on the dangers of particulate matter for the anti-smoking side and the vulnerability of revenues for the casino industry, even as the American Gaming Association reported record-breaking revenues in 2022 for in-person casino gambling beyond the growth of sports betting and online gambling.

Casinos were shut down for several months in spring 2020 as part of the nationwide effort to mitigate the spread of the coronavirus. Rules governing reopening, including masking and physical distancing requirements and bans on smoking, varied by state and, in some cases, by casino operator and community.

After suffering pandemic-era losses, some casino executives, and at least one union representing workers, leaned into a 2021 report commissioned by the Casino Association of New Jersey to combat efforts to ban or restrict smoking at their properties. Using data from 2019, the report suggests that as many as 2,500 Atlantic City casino workers could lose their jobs and tax revenue could fall by as much as $44 million in the first year if smoking is banned in New Jersey but not in neighboring Pennsylvania. Both states considered prohibitions on casino smoking in 2023; New Jersey lawmakers didn’t pass their bill and Pennsylvania’s remains in limbo.

Brian Christopher, a social media influencer specializing in casinos and gambling, said he has heard the arguments about lost business before — and is unconvinced. “People are not driving or flying to a casino to have a cigarette,” he said.

Still, officials in some places are persuaded by arguments about depressed tax revenue. Last spring, Shreveport, Louisiana, officials repealed a 2020 ban on smoking in casinos. Those pushing the repeal said local gambling taxes fell when gamblers left for nearby casinos where they could smoke. The new ordinance allows smoking on 75% of the casino floor.

And Churchill Downs Inc. announced in June it was moving a gambling facility planned for empty mall space in Owensboro, Kentucky, to a location outside the city limits. Though the company declined to comment for this article, the city’s mayor told the Messenger-Inquirer newspaper that a primary reason for the move was the city’s long-standing voter-approved smoking restrictions, which do not exempt casinos.

Kanika Cunningham, director of the St. Louis County Department of Public Health in Missouri, was part of an effort last year to end a casino loophole in her county’s 2011 indoor smoking ban. But after pushback from the gambling company Penn Entertainment, a compromise was reached allowing smoking on 50% of a casino’s floor.

“It’s a balance and one that we feel the marketplace should determine, particularly in such a competitive environment with other gaming facilities nearby and in neighboring states,” said Jeff Morris, Penn Entertainment’s vice president of public affairs and government relations.

Penn Entertainment employs “state of the art ventilation systems, extremely high ceilings,” and “adequate separation of smoking and non-smoking areas,” he wrote in an email to KFF Health News.

The problem, Cunningham said, is that secondhand smoke cannot be contained to a single location in a big room.

“There’s no safe amount, and trying to restrict it to a certain area isn’t going to work,” she said.

Filtration systems can remove much of the visible smoke, as well as the odor, from indoor spaces even when lots of people are smoking, creating the impression of clean air. But existing technology does not eliminate the dangerous particulates in cigarette smoke, according to a 2023 report from the American Society of Heating, Refrigerating and Air-Conditioning Engineers, or ASHRAE.

A study published in 2023 for the National Institutes of Health evaluated particulate matter at eight Las Vegas casinos that allowed smoking and one that did not. In casinos where smoking is allowed, particulate levels were significantly higher — even in areas designated as nonsmoking — than at the nonsmoking casino.

And in ventilated casinos where indoor smoking is allowed, one study showed, workers can have nicotine levels as much as 600% higher than employees exposed to smoking in other workplaces.

Secondhand smoke can cause coronary heart disease, stroke, lung cancer, and other diseases. Some studies have shown a link to breast cancer, although more research is needed, according to the National Cancer Institute.

The pandemic raised awareness of the dangers of airborne particulates, giving smoking bans fresh momentum, said Andrew Klebanow, co-founder of the independent industry consulting group C3 Gaming, which produced a report in 2022 largely refuting the economic risk of casinos going smoke-free.

Indeed, more than 1,000 U.S. casinos and other gambling properties now ban smoking, including more than 140 tribal casinos, according to Americans Nonsmokers’ Rights Foundation.

New Mexico’s tribal leaders collectively agreed to maintain smoking bans when pandemic restrictions were lifted, said Denis Floge, chief executive of Acoma Business Enterprises and Sky City Casino in North Acomita Village. Employee health has improved, he said, qualifying the casino for rebates on its insurance premium. Cleaning and replacement costs for carpets and equipment fell, he said, and the tribes “haven’t missed a beat” on revenues.

Some guests have grumbled about having to go outside to smoke, Floge said, but that’s about it. “We don’t have anybody who jumps up and down, or throws a fit and says, ‘I’m leaving and never coming back!’” he said.

Casino executives who oppose smoking restrictions overlook people who want to enjoy the “great food and the great entertainment, but won’t step foot in a casino because they get hit by a blast of smoke as soon as they step in,” said Pete Naccarelli, a Borgata dealer and one of three co-founders of the advocacy organization Casino Employees Against Smoking’s Effects.

He said they founded the group, which has chapters in New Jersey, Kansas, Pennsylvania, Rhode Island, and Virginia, after his casino put out ashtrays at 12:01 a.m. the day the pandemic-related smoking ban officially ended. Borgata did not answer requests for comment.

The industry-commissioned report on New Jersey suggests that while more nonsmokers might frequent casinos once smoking is banned, they probably would not make up for the revenue lost if smokers choose other venues or when smokers take breaks from gambling to light up.

But Brady, now cancer-free after chemotherapy and a full mastectomy, believes that if policymakers spent some time breathing the same air she and her co-workers do they’d act more quickly to ban smoking in casinos, rather than prioritize tax revenues. “Our lives are more important,” she said.

(KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs of KFF — the independent source for health policy research, polling and journalism.)

©2024 KFF Health News. Distributed by Tribune Content Agency, LLC.

U.S. workers are getting smaller bonuses, a sign that belt-tightening employers aren’t as concerned about losing talent as in recent years.

The average cash bonus paid to employees last month was $2,145, down 21% from the previous year, according to payroll software company Gusto, which tracks payments made by more than 300,000 small businesses. Small businesses employ nearly half of all private-sector workers in the U.S., according to government data.

Every industry posted a decline, ranging from 3.8% for technology firms to 36% for tourism and transportation companies.

Not only were bonuses smaller, but fewer workers got them in most industries. Sixteen out of the 22 industries tracked by Gusto saw declines in the share of workers that received any sort of bonus, with the biggest drop coming at arts and entertainment firms. Compared with 2021, 6.9% fewer workers got a bonus in 2023.

“What surprised me was some of the industries where we’ve been talking about challenges finding talent, like food and beverage, health care and retail,” said Liz Wilke, principal economist at Gusto. “I didn’t expect to see the magnitude of the declines in those sectors specifically.”

Several factors drove the double-digit decline, Wilke said. Businesses are not hiring as aggressively as they were a year ago, according to data from the Federal Reserve Bank of St. Louis. Fueled by soaring inflation and workers quitting at a record clip, businesses doled out more generous compensation packages over the past two years, so there’s less money in those coffers now. The rate at which workers voluntarily quit ticked down in November to the lowest since September 2020. With workers less confident in their ability to find other jobs, employers are less inclined to be as generous come bonus time.

That stinginess was also reflected in a November survey of companies of all sizes by outplacement firm Challenger, Gray & Christmas, which found that 34% of companies didn’t award a bonus in 2023, up from 27% the previous year.

The biggest payouts went to finance workers, many at boutique investment firms, with an average bonus of $13,255, according to Gusto. Still, that’s down about 12% from the roughly $15,000 paid out in 2022 and 2021. The falloff mirrors what workers at Wall Street’s biggest banks will endure this year, as business has slowed and companies like Citigroup Inc. and others pare back expenses, according to projections from compensation consultant Johnson Associates. On Tuesday, Deutsche Bank AG’s Chief Financial Officer James von Moltke said a “difficult market” will be reflected in staffers’ bonuses.

Bonuses in the tech sector dropped, on average, $672 from 2021, when talent was much more scarce. Over the past two years, tech firms of all sizes have slashed more than 265,000 jobs in streamlining efforts, according to Challenger, Grey & Christmas. Cuts have continued in the new year, with Alphabet Inc.’s Google and Amazon.com Inc.’s Twitch unit trimming headcount.

Merit-based salary increases will also see slower growth this year at larger employers, although the raises remain above pre-pandemic levels, data from Aon Plc and Mercer has shown. Companies have greater flexibility to adjust bonuses to respond to changing economic circumstances than they do with salaries, according to Liz Supinski, director of research and insights at WorldatWork, a nonprofit that provides education for human-resources professionals.

To be sure, demand for workers is still strong, and unemployment remains low. But “turbulence lurks on the edges,” according to Nick Bunker, economic research director for North America at job site Indeed. “Job gains are clearly slower than this time last year.”

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©2024 Bloomberg L.P. Visit bloomberg.com. Distributed by Tribune Content Agency, LLC.

Europe’s expansive rail network is constantly evolving, and each year, early December sees new connections and services appear on schedules across the continent for the calendar year ahead. These new train journeys often reflect travel trends or technological advances, offering travelers more direct or frequent connections between European destinations.

The following are some of the noteworthy new routes that will shape European rail travel in 2024.

Berlin-Paris

After a 10-year hiatus, there is once again a night train connecting the German and French capitals, and it’s the only direct rail connection between the cities, period. Launched in early December by OBB (Austrian Railways) under their Nightjet range, this overnight service will initially run three times a week in both directions, with the expectation of graduating to a nightly service by the end of 2024.

Madrid-Oviedo

The result of a massive infrastructure project that took nearly two decades, Spain has launched high-speed trains between the nation’s capital and the gorgeous (and relatively undiscovered) Asturias region. The sleek trains will whisk travelers through scores of tunnels between the capital and the lovely cathedral city of Oviedo, a city famed for its atmospheric streets, gastronomic delights and tasty cider.

Brussels-Prague

Last summer came the long-awaited debut of the startup night train company European Sleeper. Now, the brand has announced an extension of its Brussels to Berlin night train to Prague, which will start on March 25, 2024, and run three times a week.

Zurich-Munich

These two cities are already well connected by smart, speedy trains that take travelers from Bavaria to the heart of Switzerland in just over 3 1/2 half hours. From April 2024, there will be added departures on the line on Fridays and Sundays.

Munich-Warsaw

Instead of going straight north, this night train will head from Munich into Austria before it curls up towards Poland. Along the way, it will make stops at A-list tourist destinations like Salzburg and Krakow, providing a key transport link for travelers exploring Central Europe.

Amsterdam-Berlin

A rail connection between the Dutch and German capitals has a long history, but the time it takes to get between them will get attention in 2024. That’s because a half-hour has been shaved off the journey due to technological advances and creative route management. It will now take you 5 hours and 52 minutes instead of 6 hours and 20 minutes. When you factor in check-ins and transport from the city center to outlying airports, this compares very favorably to flying indeed.

Vilnius-Riga

Up north, these two beautiful Baltic capitals will soon be connected by rail for the first time since the pandemic. Scheduled to start in late December, the journey between Lithuania and Latvia will take just over 4 hours and will make it possible to explore the full length and breadth of this special corner of Europe by rail.

Hamburg to Vienna & Innsbruck

Separate night trains have departed the northern port city of Hamburg headed for Austria for a while now (and vice-versa), but they got a glow-up in early December. This route is the first in Europe to see OBB’s brand-new Nightjet trains that feature sleek modern interiors, tech comforts (think mood lighting & USD charging stations), mini-cabins for solo travelers and showers & bathrooms in every sleeping compartment. Eventually, they will roll out all over Europe, but in 2024, this route is your only chance to experience the “future” European night trains.

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©2024 Northstar Travel Media, LLC. Visit at travelpulse.com. Distributed by Tribune Content Agency, LLC.

It was a whirlwind long awards weekend, as the Critics Choice Awards and the Emmys chased the Golden Globes last weekend. And Oscar nomination voting closes Jan. 16, so there will be a lull in awards campaigning — at least for a week — until the nominations come out on Jan. 23. But there’s no rest for the Hollywood weary, as the Sundance Film Festival kicks off this week, and no doubt some awards contenders for next year will emerge from Park City, Utah, in no time.

Since the Emmys usually air in September, but the show was pushed to January due to the writers’ and actors’ strikes this past fall, it’s felt a bit confusing to drop these TV awards in the midst of the condensed and accelerated Oscar campaign. But there was much overlap among the Globes, the Emmys and the Critics Choice Awards, with “The Bear” sweeping for best comedy and “Succession” for best drama, even though often “Succession” is the funnier show and “The Bear” the more moving and dramatic. Up is down, black is white and drama is comedy when it comes to the current television era apparently.

“The Bear” star Ayo Edebiri took the three-peat, winning best supporting actress prizes at the Globes, Critics Choice and Emmys. Her co-star, Jeremy Allen White, also won the Globe and Critics Choice, with co-star Ebon Moss-Bachrach winning supporting actor Emmy and Critics Choice awards as well, and the show taking best comedy across all three awards bodies too, plus writing and directing awards. Edebiri’s comedy “Bottoms” is also nominated for a couple of Independent Spirit Awards (available to stream on MGM+ or rent). If you haven’t seen “The Bear” yet, which is set in a Chicago restaurant, two seasons are streaming on Hulu.

“Succession” had the same success, with HBO’s hit series about the Roy business dynasty sweeping the acting categories for Kieran Culkin, Sarah Snook and Matthew Macfadyen, and taking home best drama series, as well as writing and directing awards. Again, it is hard to imagine anyone who loves TV who has yet to see “Succession,” which concluded its run last year, but it’s always good for a rewatch on Max.

The Netflix series “Beef” swept across all three awards shows as well, picking up prizes for best limited series and for Steven Yeun and Ali Wong in the limited series acting categories. At the Critics Choice Awards, co-star Maria Bello won the supporting actress prize. Created by Lee Sung Jin, the 10-episode “Beef” follows two strangers who are involved in a road rage incident that inspires an escalating feud. Stream it on Netflix.

The ABC comedy “Abbott Elementary” also did well at the Emmys (stream it on Hulu), as well as perennial favorite Jennifer Coolidge from HBO’s “The White Lotus” (stream it on Max).

But there were some other more surprising wins over this awards weekend too. Niecy Nash-Betts won the supporting actress in a limited series Emmy for her role on the Ryan Murphy produced Netflix series “Dahmer — Monster: The Jeffrey Dahmer Story,” while Paul Walter Hauser took the supporting actor Emmy in the same category for his role on the Apple TV+ series “Black Bird.”

At Critics Choice, Jonathan Bailey won the supporting actor in a limited series award for “Fellow Travelers,” which follows a decadeslong romance between two men who meet in the 1950s at the height of McCarthyism. Stream it on Paramount+ on Showtime. The inventive animated series “Scott Pilgrim Takes Off,” inspired by “Scott Pilgrim vs. the World” won the Critics Choice Award for best animated series. Stream it on Netflix.

Finally, “RuPaul’s Drag Race” won the Emmy for best reality competition program, and host RuPaul is now the most awarded host at the Emmys ever, which is a delightful fun fact about the funny, heartwarming, and addictive reality show, now airing it’s 16th season (airing on MTV). The Emmy-winning 15th season is streaming on Paramount+.

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(Katie Walsh is the Tribune News Service film critic and co-host of the “Miami Nice” podcast.)

©2024 Tribune Content Agency, LLC

Salmon is versatile, easy to find and quick to cook, so it’s no mystery why it makes its way onto so many dinner tables.

While cooking it can be tricky — especially if you want your salmon to be nicely browned on the outside and moist, silky and tender on the inside — there are a couple of important steps to take that can make getting a delicious result almost foolproof.

Start by brining the salmon before cooking it, which solves more than one problem. First, it improves the texture. Giving it a soak in saltwater helps ensure that the salmon has a nice flake but is also ultra-moist. Second, it infuses more flavor into the flesh. Third, it makes the salmon look better by reducing the amount of albumin (aka “the white stuff”) from seeping out of the flesh during the cooking process.

Of course, there are many ways to cook salmon, but I like the roasting method used in this week’s recipe for Pecan-Crusted Honey Mustard Salmon, because it achieves the previously mentioned “browned on the outside, moist on the inside” results.

It starts out in a smoking-hot oven, which kickstarts the browning process, then the heat is immediately turned down to a low temperature to complete the cooking process and preserve the salmon’s moisture.

In this recipe, I’m coating the salmon fillets with a mixture of honey and mustard, along with a crunchy pecan topping, both of which dial up the flavor/texture factors. But you could leave off the pecans or use pesto instead of the honey mustard.

The options are endless, so it’s easy to make this dish your own.

Pecan-Crusted Honey Mustard Salmon

Serves 4.

Crunchy, sweet, salty and savory, this salmon recipe has it all. Oh, and it’s ultra-easy, which is why it’s sure to become your new go-to weeknight dinner. From Meredith Deeds.

• 5 tbsp. kosher salt

• 4 (6- to 8-oz.) skin-on salmon fillets

• 1 tbsp. olive oil

• 2 tbsp. Dijon mustard

• 2 tbsp. honey

• 1/2 c. chopped pecans

• Lemon wedges, for serving

Directions

In a medium bowl, combine 5 tablespoons of salt with 4 cups of water. Stir until salt is dissolved. Place salmon in a bowl or casserole dish and pour the water over the top. The water should cover the salmon. (If necessary, make another batch of saltwater, so you have enough water to submerge the salmon.) Cover the dish and refrigerate it for 15 to 30 minutes.

Preheat oven to 500 degrees.

Thoroughly pat salmon dry with paper towels. Rub fillets evenly with oil and place skin-side down on a rimmed baking sheet. In a small bowl, stir together the mustard and honey. Brush over the top and sides of the salmon fillets. Sprinkle the pecans over the top.

Reduce oven temperature to 275 degrees. Roast until the centers of the thickest part of the fillets are still translucent when cut into with a paring knife or an instant-read thermometer inserted in thickest part of fillets registers 125 degrees, 9 to 13 minutes. Transfer fillets to individual plates or platter. Serve with lemon wedges.

©2024 StarTribune. Visit at startribune.com. Distributed by Tribune Content Agency, LLC.

When Phyllisa Deroze was told she had diabetes in a Fayetteville, North Carolina, emergency department years ago, she was handed pamphlets with information on two types of the disease. One had pictures of children on it, she recalled, while the other had pictures of seniors.

Deroze, a 31-year-old English professor at the time, was confused about which images were meant to depict her. Initially, she was diagnosed with Type 2 diabetes, as shown on the pamphlet with older adults. It would be eight years before she learned she had a different form of diabetes — one that didn’t fit neatly on either pamphlet.

The condition is often called latent autoimmune diabetes of adults, or LADA for short. Patients with it can be misdiagnosed with Type 2 diabetes and spend months or years trying to manage the wrong condition. As many as 10% of patients diagnosed with Type 2 diabetes might actually have LADA, said Jason Gaglia, an endocrinologist at the Joslin Diabetes Center in Boston.

Deroze and three other LADA patients who spoke with KFF Health News, all Black women, are among those who were initially misdiagnosed. Without the correct diagnosis — which can be confirmed through blood tests — they described being denied the medicines, technology, and tests to properly treat their diabetes. Three of them wonder if their race played a role.

“That does seem to happen more frequently for African American patients and for other minoritized groups,” said Rochelle Naylor, a pediatric endocrinologist at the University of Chicago who researches atypical forms of diabetes. “Doctors, like any other person walking this planet, we all have implicit biases that impact our patient experiences and our patient care delivery.”

Black patients have long struggled with bias across the U.S. health care system. In a recent KFF survey, for example, 55% of Black adults said they believed they needed to be careful at least some of the time about their appearances to be treated fairly during medical visits. Hospital software used to treat patients has been investigated for discrimination. Even a common test used to manage diabetes can underestimate blood sugar levels for patients who have sickle cell trait, which is present in nearly 1 in 10 African Americans.

LADA ostensibly has nothing to do with race, but misconceptions about race, weight, and age can all lead doctors to misdiagnose LADA patients with Type 2 diabetes, said Kathleen Wyne, an endocrinologist who leads the adult Type 1 diabetes program at Ohio State University.

Type 2 diabetes develops in people, often over age 45, whose bodies cannot properly regulate their blood sugar levels. Type 2 accounts for at least 90% of diabetes cases in the U.S. and has a high prevalence among African Americans, Native Americans, and Hispanic populations. It can often be managed with lifestyle changes and oral medications.

LADA is more akin to, or even thought to be another form of, Type 1 diabetes, an autoimmune condition once dubbed “juvenile diabetes” because it was most often diagnosed in children. Type 1 occurs when the body attacks its cells that produce insulin — the naturally occurring hormone that regulates blood sugar by helping turn food into energy. Without insulin, humans can’t survive.

LADA is difficult to diagnose because it progresses slowly, Gaglia said. Typical LADA patients are over 30 and don’t require injectable insulin for at least six months after diagnosis. But, like Type 1 patients, most will eventually depend on injections of pharmaceutical insulin for the rest of their lives. That delay can lead physicians to believe their patients have Type 2 diabetes even as treatment becomes less effective.

“If you have someone who comes into your office who is obese and/or overweight and may have a family history of Type 2 diabetes — if you’re a betting person, you bet on them having Type 2 diabetes,” Gaglia said. “But that’s the thing with LADA: It unmasks itself over time.”

Mila Clarke, who lives in Houston, finally saw an endocrinologist in November 2020, more than four years after being diagnosed with Type 2 diabetes. During that visit, she recounted her struggles to manage her blood sugar despite taking oral medications and making significant changes to her diet and exercise regimens.

“‘What you just explained to me, I believe, is a classic case of LADA,’” Clarke recalled being told. “‘Has anybody ever tested you for Type 1 antibodies?’”

Because both Type 1 diabetes and LADA are autoimmune conditions, patients will have antibodies that Type 2 patients typically don’t. But, as Clarke recounted, getting tested for those various antibodies isn’t always easy.

Clarke, now 34, had leaned into her Type 2 diagnosis when she received it in 2016 at age 26. She started a blog with nutrition and lifestyle tips for people with diabetes called “Hangry Woman,” and garnered tens of thousands of followers on Instagram. Clarke said she wanted to fight the stigma around Type 2 diabetes, which stereotypes often associate with being overweight.

“Some of the harshest comments that I had gotten were from people with Type 1 who were like, ‘We’re not the same. I didn’t cause this. I didn’t do this to myself,’” Clarke said. “Well, neither did I.”

Clarke also felt her initial doctor thought she just wasn’t working hard enough.

When she learned about continuous glucose monitors, wearable electronic devices that allow patients to track their blood sugar around the clock, she asked her primary care doctor to prescribe one. The monitors are recommended for patients with Type 1 and, more recently, some with Type 2. “He flat-out told me, ‘No. It’s going to be too much information, too much data for you,’” she recalled.

Clarke switched to a different primary care doctor who she felt listened better and who prescribed a continuous glucose monitor. (Clarke later became a paid ambassador for the company that manufactures her device.) The new doctor eventually referred Clarke to the endocrinologist who asked if she’d been tested for antibodies. The test came back positive. Clarke had LADA.

“In the health care system, it’s really hard to vocalize your needs when you are a woman of color because you come off as aggressive, or you come off as a know-it-all, or you come off as disrespectful,” Clarke said. “My intuition was right this whole time, but nobody believed me.”

Immediately, Clarke noticed an “eye-opening” difference in how she was treated. She started insulin injections and was referred to a dietitian and a diabetes educator. She wondered: Why wasn’t it easier to get tested for antibodies?

Those tests are imperfect and can have false positives, said Gaglia of the Joslin center. Still, Ohio State’s Wyne argued that every diabetes patient should be tested for at least the most common antibody associated with Type 1.

“Aren’t you saving lives if you’re identifying the Type 1 before they come in with DKA and die?” Wyne asked, referring to diabetic ketoacidosis, a serious complication of diabetes most commonly associated with Type 1.

Deroze started asking her doctor for antibodies tests in 2017 after reading about a Type 2 blogger’s experience being newly diagnosed with LADA.

Her endocrinologist denied her requests. She thinks the doctor thought it was impossible for her to have an autoimmune form of diabetes because of her race and weight. She sought a second opinion from a different endocrinologist, who also refused to test her.

“I just felt unseen,” Deroze said.

After a bout with diabetic ketoacidosis in 2019, Deroze finally persuaded her gynecologist to test her for antibodies. The results came back positive. One of the endocrinologists apologetically prescribed insulin and, later, an insulin pump, another ubiquitous piece of technology for people with Type 1.

And for the first time, she encountered the words “diabetes is not your fault” while reading about Type 1 diabetes. It felt like society was caring for her in a way it hadn’t when she was misdiagnosed with Type 2. That’s troubling, she said, and so is how long it took to get what she needed.

“My PhD didn’t save me,” said Deroze, who now lives in the Miami area. “You just see the color of my skin, the size of my body, and it negates all of that.”

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(KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs of KFF — the independent source for health policy research, polling and journalism.)

©2024 KFF Health News. Distributed by Tribune Content Agency, LLC.