The White House Is Cutting More Funds for Overseas Health Organizations Linked to Abortion

The Trump administration announced Monday that it will expand the denial of U.S. funding for foreign health organizations that provide abortion services or even information about abortion. The disruption in funding could threaten hundreds of clinics globally that fight HIV, malaria, Zika and Ebola.

“U.S. taxpayer money should not be used to support foreign organizations that perform or actively promote abortion as a method of family planning in other nations,” a senior administration official said. The official added that the policy will now be called “Protecting Life in Global Health Assistance,” though it is more commonly referred to as the Global Gag Rule or the Mexico City Policy.

The policy applies to some $ 8.8 billion in federal funding given toward global health assistance. The amount of funding appropriated for such programs will not be affected, the official said, but organizations that receive funding will be required to pledge not to “perform or actively promote abortion.”

Read more: Here’s what the Mexico City Policy Means for Women

The policy, which was reinstated by President Donald Trump through an executive order issued on his first full day in office, is typically enforced by Republican administrations and repealed when there are Democrats in the White House.

It formerly applied only to family planning assistance provided through the State Department and the U.S. Administration for International Development (USAID), but Trump’s new provisions extend its application to funding offered through the Department of Defense.

In April, the Trump administration announced that it would discontinue funding for the U.N.’s family planning and reproductive health agency, UNFPA, claiming that the agency had links to “coercive abortion or forced sterilization” programs in China — a claim UNFPA said was “erroneous.”

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Hepatitis C Is Spiking Among Young People

Cases of hepatitis C in the United States have nearly tripled within a five-year period, reaching a new 15-year high of around 34,000 new hepatitis C infections in 2015, federal health officials reported. Experts attribute the higher rates to more injection drug use during the ongoing opioid epidemic.

The new report from the U.S. Centers for Disease Control and Prevention (CDC) shows that cases of the disease rose substantially, from 850 new cases in 2010 to 2,436 cases in 2015. However, because most people with hepatitis C do not know they have the disease and most new infections go undiagnosed, the CDC estimates there were actually 34,000 new infections in 2015.

The greatest number of new infections are among young people from ages 20 to 29, a spike the CDC says is due to higher use of injection drugs in the opioid epidemic. “We must reach the hardest-hit communities with a range of prevention and treatment services that can diagnose people with hepatitis C and link them to treatment,” said Dr. Jonathan Mermin, director of CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, in a statement.

Most people living with hepatitis C are baby boomers, a population the CDC says is six times more likely to have an infection compared to other age groups. There are an estimated 3.5 million Americans living with hepatitis C, and the CDC reports that nearly 20,000 people died from the disease in 2015.

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This Is How Much Praise Kids Really Need

To help children thrive emotionally and socially, aim to praise them for their good behavior five times a day, a new study suggests. The research, presented at the British Psychological Society’s annual conference, found that parents who did exactly that saw a boost in their kids’ wellbeing and a drop in hyperactivity and inattention.

For the study, which has not yet been published in a peer-reviewed journal, researchers from De Montfort University in England asked 38 parents of 2- to 4-year-olds to complete questionnaires about their children’s behavior and wellbeing. Some of the parents were also given information about how and when to praise their children for good behavior and were asked to keep track of how many times they did so each day.

After four weeks, the parents who said they praised their kids five times a day saw an improvement in their children’s wellbeing, compared to those who weren’t keeping track. Children in the praise group also had better behavior and reduced levels of hyperactivity and inattention, according to the parents’ responses.

Sue Westwood, senior lecturer at De Montfort University, said that praising a child is a “simple, cost effective intervention” that when used on a regular basis can have a significant impact. “Improved behaviour and wellbeing can result simply from ensuring that a child’s positive actions are rewarded with praise and parents are seen to be observing their good behavior,” she said in a press release.

The study is based on De Montfort’s Five Praises campaign, designed to encourage parents and caregivers to give frequent positive and loving attention to children, especially very young kids. On the campaign’s website, parents can download a weekly chart—similar to the ones used in the new study—to track their five daily instances of positive reinforcement.

“Sometimes it’s easier to criticize than it is to compliment,” the researchers wrote in materials distributed to parents in the study. “Bad behavior is more obvious than good behavior—you’re much more likely to notice when your child is yelling than you are to notice when your child is quietly reading a book.”

But research has shows that regular appreciation and praise fosters feelings of closeness and love in babies and toddlers, the study authors say, and also encourages them to keep up their good behavior.

Researcher Carole Sutton, co-founder of the Five Praises campaign, says that parents should take the opportunity to “catch” their children being good, and to acknowledge their everyday efforts and achievements: toddlers brushing their teeth, learning to ride a tricycle or caring for pets or siblings, for example. At the same time, she says, parents should also set firm boundaries so that children don’t grow to expect unwavering approval.

Five praises a day may not be a magic number; Sutton chose it as a good goal because it echoed the popular advice to eat five servings of fruit and vegetables a day. “You might use fewer or more,” she says, “but the important point is that the children should hear positive messages frequently and over weeks and months, not just for a day or two.”

Sutton also says that not just parents, but grandparents, teachers and anyone who interacts with children of any age should make an effort to praise behaviors they want to encourage in their kids. If they do, she says, “they will almost certainly see a move to more positive patterns of behavior in families, classrooms, in shops—everywhere.”

Health – TIME

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This Week in Health: Flesh-Eating Bacteria and the Perks of Coffee

This week brought the harrowing yet inspiring story of a woman who survived an infection from flesh-eating bacteria. It also provided the bottom line on coffee at last. (You’re in luck: it’s good for you.) Here’s what else caught our attention in health news this week. Sign up for our newsletter for more.

I survived flesh-eating bacteria—and it changed my life forever

One woman shares her story of surviving flesh-eating bacteria but losing her leg, foot and hands to the infection.

You Asked: Should I use an air purifier?

woman opening curtains
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It’s a good idea for people with allergies and asthma. But choosing the wrong type could do more harm than good.

These are the filthiest places in your kitchen

Pear in a refrigerator
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Think you have a spotless setup? Most home kitchens would receive major health violations if they were rated the same way that restaurants are, according to the shocking results of a new study.

When cancer patients should ask for genetic sequencing

Genetic information about tumors is paving the way to better treatments for cancer, according to new research.

The case for drinking coffee is stronger than ever

Too early TIME health stock
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With so much conflicting evidence, it can be tough to know if coffee is good or bad for you. But experts have a new appreciation for the health benefits of coffee.

People with HIV are living 10 years longer

The human immunodeficiency virus (HIV) is no longer as deadly as it used to be, and life expectancy is increasing for those infected, finds a new report.

Taking ibuprofen daily raises your heart attack risk

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Over-the-counter pain relievers, like ibuprofen and naproxen, can increase the risk of heart attacks by a significant amount, a new study finds.

Hepatitis C is spiking among young Americans

Experts blame the opioid epidemic and a rise in injectable drug use.

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Teen Drinking Reaches Lowest Point in 25 Years, CDC Says

Teens are drinking significantly less than they used to.

Underage drinking among teens has reached a new low, ABC News reports. The percent of teens who said they have at least one drink per month dropped from 50.8% in 1991 to just 32.8% in 2015 in a new report from the Centers for Disease Control and Prevention (CDC).

Despite the overall decrease, researchers say binge drinking is still a problem. Of those teens who reported drinking, 57.8% said they had five drinks in a row, and 43.8% said they had drunk at least eight drinks in one sitting.

Researchers examined data from the national Youth Risk Behavior Survey, which asks students to answer a self-administered questionnaire. The sample size ranged from 10,904 to 16,410 students between 1991 and 2015, according to ABC.

The new report found that binge drinking among teens has decreased from a high of 31.5% of teens in 1999 to 17.7% of teens in 2015.

Teen drinking has been falling for years, but the CDC and other groups are still concerned about underage drinking. Some research has shown binge drinking can lead to long-lasting problems, and the Substance Abuse and Mental Health Services Administration calls teen drinking a “considerable public health challenge.”

Researchers said one reason for the decrease in teen drinking may be state policies aimed at the issue, according to ABC. They say other policies such as taxes on alcohol, laws that regulate where people can buy or consume alcohol or rules around alcohol advertising might help curb teen drinking going forward.

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TIME Health: Eye Health

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People With HIV Are Living 10 Years Longer

More people are living longer lives with HIV, according to a new report published in the Lancet HIV that includes data from more than 88,000 people from 18 countries. People who contracted the virus in recent years are living 10 years longer than people who were infected in the mid 1990s. A 20 year old infected with HIV today can expect to live about 78 years, almost as long as people without the disease.

The researchers, part of the international Antiretroviral Therapy Cohort Collaboration, say that the introduction of anti-HIV drugs beginning in the early 1990s played a large role in helping people live longer with HIV. The earliest HIV therapies involved dozens of pills taken at different times of the day, but today, many anti-HIV regimens include only a single pill containing a combination of medications taken once a day. This makes it more likely that people will take the drug daily. Today’s drugs are also better at controlling the virus and carry fewer side effects, which improved their ability to extend life expectancy.

MORE: The End of AIDS

But the drugs alone can’t account for all of the improvement in survival, the study authors say. Since more people with HIV are able to keep their infections under control, doctors are focusing more on also treating their other illnesses, such as heart disease and diabetes, which tend to increase with age. Better healthcare overall for HIV patients is also helping them to live longer.

As encouraging as the results are, they also reveal that for some groups of people who are infected, the gains aren’t as great. People who inject drugs, for example, show slower improvements in life expectancy, likely because they have less access to healthcare and the powerful medications that can keep HIV suppressed.

MORE: No Baby Should Be Born With HIV. What Will It Take to Save Them All?

The improvements in survival confirm that existing HIV therapies work, the researchers argue, and that extending lives even further requires doesn’t require the discovery of new drugs but better distribution of the ones already available. People with HIV are still not living as long as uninfected people, but making sure that they are given the support they need to not only access the medications but to keep taking them may change that.

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Taking Ibuprofen Daily Raises Your Heart Attack Risk

Ibuprofen, naproxen and celecoxib are among the most commonly used drugs in the U.S. They don’t require a prescription, and they’re a quick answer to all kinds of pain. But lately there’s been growing evidence that non-steroidal anti-inflammatory drugs (NSAIDs) may not be as benign as people think they are. (For more recent reporting on the potential side effects of NSAIDs, read this.)

In general, NSAIDs are considered safe when used as directed—which is to say occasionally, for spot relief of pain. More and more people, however, are relying on them for long term use, and at higher doses. Experts—and a growing body of science—say that’s where problems can start.

MORE: Ibuprofen May Not Be As Safe As You Think

In the latest study, published in the journal BMJ, researchers found that some risks can appear after even a few days of using NSAIDs. Compared with people who didn’t take the painkillers, those who did had a 20% to 50% greater chance of having a heart attack. The risk was higher for people who took 1,200 mg a day of ibuprofen—the equivalent of six standard tablets of Advil—and 750 mg a day for naproxen, the equivalent of roughly three and a half standard Aleves.

The researchers pooled data from several large studies on the drugs and their health effects. In all, more than 446,000 people who used the non-prescription painkillers were included. Among them, more than 61,000 had a heart attack. People who took NSAIDs for even a week had a significantly higher risk of having a heart attack; the highest risk occurred for those taking them for about a month. (After a month, the risk didn’t appear to increase further — the researchers think that’s because everyone who was vulnerable to the drugs’ effects on the heart would have experienced heart problems by then.)

The results confirm those from earlier studies that also found a heightened risk of heart problems in NSAID users, but the large number of people in this analysis—and the more detailed look at how long people were taking the drugs—makes the connection even stronger. The researchers also accounted for other possible factors that could connect NSAID users and heart problems, such as diabetes, high cholesterol levels and previous history of heart disease. Even after those adjustments, the linked remained significant.

The study also confirmed that newer NSAIDs like celecoxib, known as COX-2 inhibitors, which were originally thought to cause more heart problems than traditional NSAIDs, were not more risky when it comes to heart attacks.

As TIME reported previously, some studies found a 19% higher risk of having heart trouble among NSAID users compared to people who didn’t use the drugs. Other studies have found higher risk of hearing loss and miscarriage as well. Those led the Food and Drug Administration to add a warning on NSAID labels about the risks of taking the drugs, especially for long periods of time at high doses.

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Swearing Can Be Good for You, According to Science

The next time you could use a little burst of power—whether you’re biking up a steep hill or simply trying to open a jar of pickles—it might help to utter a few not-safe-for-work words while giving it your all. According to a new study, swearing seems to increase strength for short periods of time.

Previous research has shown that using profanity can increase pain tolerance. Scientists think this might be because it stimulates the body’s sympathetic nervous system—the system that revs the heart rate and activates the body’s “fight or flight” response when it senses some kind of threat.

Researchers from Keele University and Long Island University Brooklyn hypothesized that this might also give people a quick strength boost, as well. To test their theory, they asked a total of 81 participants to complete short tests of anaerobic and isometric power. Some rode an exercise bike at maximum intensity for 30 seconds; others squeezed a hand-grip device as hard as they could.

They measured participants’ performance on these tests under two circumstances: once while repeating a curse word of their choosing every three seconds, and once while repeating a neutral word—something to describe a table in the room, like “flat” or “round.”

As predicted, the volunteers produced more pedaling power and had stronger hand grips while they were cursing. Surprisingly, though, the researchers found no significant differences in heart rate, blood pressure, and skin conductance (a measure that increases physiological arousal) between the swearing and non-swearing scenarios.

This suggests that the sympathetic nervous system may not be the driving factor after all, says co-author David Spierer, former associate professor of athletic training, health, and exercise science at Long Island University Brooklyn. Instead, the researchers think cursing may allow people to “shut down their inhibitions,” says Spierer, “and somewhat veil the effort and the pain of this really difficult task.”

In this way, Spierer says, using swear words might be helpful in any circumstance where muscle strength and a sudden burst of force or speed is required. “If you’re trying to open a jar of pickles and it’s really tough, I’m not going to say that cursing will definitely enable you to open it,” he says. “But I do feel that cursing could decrease your awareness of what it is you’re doing, and that could actually make it more forceful.” The same could go for athletic events, too. “If you’re not really aware of the pain and difficultly, you can put more into your performance.”

MORE: How Your Smartphone Ruins Your Workout

For reasons that aren’t quite understood, a neutral word didn’t have the same effect on participants in the study. Spierer says it’s likely that everyone has different responses to profanity, as well. “In the study, some people chose more explicit words than others,” he says. He adds they were all short—mostly four letters—and repeated at a normal volume. “It’s not like they were going on a tirade and screaming at people.”

If you want to try it yourself, Spierer suggests repeating your chosen word at a structured pace, like a mantra. “We think that if you get into a rhythm and your body can predict when it’s coming, it can have more of an effect.”

The study, which has not yet been published in a peer-reviewed journal, was presented this week at the British Psychological Society’s annual conference in Brighton, England.

This article originally appeared on

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Pre-Existing Condition? Your Insurance Could Cost Up to $140,000 More Under the AHCA

Insurance premiums for people with pre-existing conditions could increase by hundreds of thousands of dollars if the American Health Care Act, which passed the House Thursday, becomes law in its current form.

The AHCA allows insurers in states that offer a high-risk pool option to charge people with pre-existing conditions more for insurance if the patients do not maintain continuous coverage. This insurance underwriting practice is currently banned by the Affordable Care Act, and is one of the health law’s most popular provisions.

But if the Senate keeps the waiver provision of the AHCA, cancer patients could see premium surcharges as high as $ 142,650, according to a report from the liberal Center for American Progress.

The CAP report estimates premium surcharges for conditions for a 40-year old with various ailments compared to a healthy 40-year-old, based on data from the Centers for Medicare and Medicaid Services. The surcharge is compared to an assumed $ 4,020 standard rate for healthy individuals.

The study finds that “individuals with even relatively mild pre-existing conditions would pay thousands of dollars above standard rates to obtain coverage.” For example, someone with asthma would experience a premium surcharge of $ 4,340, while someone who suffers from diabetes would face a $ 5,600-per-year increase. For those with serious medical conditions, the costs are exorbitantly higher.

Here are some of the other surcharges, based on CAP’s report:

Condition Surcharge as a share of standard premium Surcharge in dollars
Metastatic cancer 3,500% $ 142,650
Lung, brain, and other severe cancers 1,790% $ 72,980
Colorectal, breast, kidney, and other cancers 703% $ 28,660
Diabetes without complication 137% $ 5,600
Rheumatoid arthritis and specified autoimmune disorders 652% $ 26,580
Major depressive and bipolar disorders 208% $ 8,490
Drug dependence 502% $ 20,450
Autistic Disorder 135% $ 5,510
Seizure disorders and convulsions 179% $ 7,300
Congestive heart failure 459% $ 18,720
Asthma 106% $ 4,340
Stage 4 chronic kidney disease 286% $ 11,650
Completed pregnancy with no or minor complications 425% $ 17,320

It’s important to note that the AHCA still bans basing premiums on gender and occupation, so pregnancy may not be considered a pre-existing condition, though that is unclear.

CAP’s estimates are based on national data, so they would vary by state. But the underlying message remains: If the ACA’s protections for people with pre-existing conditions are scrapped in the GOP’s health bill, sick people in the individual market will pay much, much more for health insurance.

A separate report from the AARP found premiums in the high-risk insurance pools could exceed $ 25,000.

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Minnesota Is Experiencing Its Largest Outbreak of Measles in Nearly 30 Years

Minnesota is having its largest outbreak of measles in nearly 30 years after a number of Somalian immigrants apparently bought into the rhetoric of anti-vaccination campaigners and did not vaccinate their children.

The state has confirmed 41 cases of the disease since April 11, according to a press release from the Minnesota Department of Health, resulting in the largest outbreak this year in the U.S. despite measles being eradicated in the country the early 2000s.

Eleven patients had been hospitalized as of Friday, Doug Schultz, a spokesman for the Minnesota Department of Health, told the New York Times. All of the patients except one adult health care worker were children younger than 10, Schultz said.

Schultz said that anti-vaccine activists had “targeted” members of the Somali community in Minnesota.

Measles is highly contagious and cause severe illness and death. Andrew Wakefield, founder of the modern anti-vaccine movement, told the Washington Post Friday that he doesn’t “feel responsible at all.”

“The Somalis had decided themselves that they were particularly concerned,” Wakefield said. “I was responding to that.”

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FDA Approves ALS Treatment for the First Time in More Than 2 Decades

The Food and Drug Administration on Friday cleared a treatment for fatal neurological disorder amyotrophic lateral sclerosis (ALS), marking the first such U.S. regulatory approval in more than two decades.

The drug, known chemically as edaravone, is already sold by Japanese pharmaceutical company Mitsubishi Tanabe Pharma Corp (MTPC) in Japan and South Korea.

In the United States, the only other approved ALS medicine, generic riluzole, modestly slows the progression of the disease in some people.

After six months of treatment with edaravone on top of standard-of-care, data showed the intravenous drug reduced the rate of functional decline in patients by about a third, Dr Jean Hubble, VP of medical affairs, at MTPC’s U.S. unit MT Pharma America (MTPA), said.

ALS, whose cause is largely unknown, garnered international attention when New York Yankees player Lou Gehrig abruptly retired from baseball in 1939, after being diagnosed with the disease.

In 2014, ALS returned to the spotlight with the “Ice Bucket Challenge,” which involved people pouring ice-cold water over their heads, posting a video on social media, and donating funds for research on the condition, whose sufferers include British physicist Stephen Hawking.

The rare progressive condition attacks nerve cells located in the brain and spinal cord responsible for controlling voluntary muscles.

Eventually, the brain’s ability to start and control voluntary movement is lost, and the patient succumbs to the disease – usually three to five years from the onset of symptoms.

The FDA was expected to make its decision on edaravone by June 16. To be sold under the brand name Radicava, the drug should be available in the United States by August, MTPA Chief Commercial Officer Tom Larson said.

He declined to disclose edaravone sales data from Japan and South Korea in an interview with Reuters in anticipation of the FDA announcement.

Another promising drug for ALS is being developed by French drugmaker AB Science SA, which in March reported positive late-stage data on its drug, masitinib. The drug is now under European review.

More than 6,000 people in the United States are diagnosed with ALS each year, according to the ALS Association

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Why Bacteria Are More Threatening Than Ever

The stories are harrowing: people with simple cuts who get exposed to bacteria can end up with life-threatening, and sometimes even life-ending, infections. Antibiotics were supposed to prevent these infections and deaths. But in the U.S., about two million people become infected with bacteria that can’t be treated by antibiotics, and at least 23,000 people die from those infections every year.

MORE: The World Is Not Ready for the Next Pandemic

The bacteria behind these infections, once common. have mutated to become resistant to the dozens of antibiotics developed to wage war against them. (See exactly how that happens in the video above.) That’s a problem of our own making. Public health experts say that the superbugs are the result of years of overusing and misusing antibiotics, either by dispensing them in too-high doses or using them against minor infections or inappropriate conditions like the flu, which doesn’t respond to antibiotics. Antibiotics are also overused in farming—not just to keep infections at bay, but also as a way to encourage animals like chickens, pigs and cattle to grow larger and produce more meat. With so many antibiotics circulating in people and in animals, bacteria mutate to find ever more clever ways of becoming resistant to the drugs.

MORE: A Cautionary Tale About Antibiotics

The only way to get ahead of antibiotic-resistant superbugs is to outsmart them. In recent years, doctors have been cutting back on prescribing the drugs, and some hospitals require registries for antibiotics so they can keep track of how much are being used. Educational programs have sprung up designed to teach people about when antibiotics are appropriate, and when they aren’t. In order to fend off superbugs, we have to be as persistent as they are.

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What Happened When Oregon Sent Its Most Troubled Mental-Health Patients Into the Woods

It was nearly 70 years ago that the National Mental Health Association first observed May as Mental Health Month, a designation meant to raise awareness about mental-health issues. But a lot has changed since then in the American conversation about these problems.

One of the biggest steps was the move away from a model in which patients with serious mental-health problems were expected to live in large, typically state-run institutions. As TIME explained in 1975, the population in such institutions had been more than halved between the late 1950s and the early 1970s. Much credit for the drop was due to the development of new drugs that made it possible for outpatient treatment to be effective––and to rising costs that made such treatment more appealing. But another important factor was the growing belief that life spent entirely within a hospital’s walls was actively harmful for the patients it aimed to treat.

In 1972, that belief was on display in the pages of LIFE magazine, which sent photographer Bill Eppridge and correspondent John Frook to Anthony Lake, Ore. There, 51 of the most troubled patients at the Oregon State Hospital, including those with violent psychosis and those who had committed serious crimes under the influence of their diseases, were sent into the woods for more than two weeks, along with 51 staffers and a host of guides.

The experiment was the brainchild of the hospital’s superintendent, Dr. Dean Brooks, and Everest climber Lute Jerstad. They wondered, as Frook put it in his notes on the assignment, which were preserved in LIFE’s archives, what would happen when you took those patients “away from strict security” and put them somewhere “that had no perimeter” among “the rest of us who have not yet been certified as crazy.”

The takeaway, per Frook: “Well, it worked.”

One young woman became more comfortable with herself and thus easier for others to be around. One boy never talked much but began to smile more. A woman who had had to be physically carried for an early portion of the trip became a star camper when it turned out she could actually make a good meal out of the available supplies. Though many signs of institutionalized life carried over — used to sleeping and waking on a regular schedule, some patients would at first fall asleep at the prescribed time wherever they happened to be — many of the campers blossomed in the new environment. As LIFE reported in the version of the story that ran in print, 14 of the patients who participated in the experiment were eventually released from the hospital. Though Dr. Brooks credited outpatient counseling and drug therapy with their ability to cope in the world outside, he believed the camping trip could be given credit for lending them the courage they would need to make that change.

And the assignment, which generated a whopping 90-odd contact sheets worth of photographs, changed Frook too. As he told managing editor Ralph Graves, he had started the assignment wary of camping out, away from civilization, with people who had violent histories. But the “forced interdependence” of the trip soon changed that. Not only did he find that it was sometimes hard to tell who on the trip was a patient and who was staff, he also found that some of the very people of whom he’d once been afraid were “extraordinarily tender” to others and to him.

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A Health Care Expert Reveals 3 Things You Can Do to Lower Your Medical Bills

There’s plenty of uncertainty in health care these days as Congress wrestles with Obamacare’s fate. But there’s one thing we know for sure: The price we pay for health care keeps going up.

Even setting aside the winners and losers under the GOP proposal to replace Obamacare, the underlying bill for medical goods and services—everything from MRI scans to joint replacements to prescription drugs—continues to climb. According to the Centers for Medicare & Medicaid Services, national health spending is projected to grow at an average rate of 5.6% per year for 2016-2025, driven by projected growth in medical prices.

And that ultimately increases out-of-pocket costs for everyone, explains Elisabeth Rosenthal, editor-in-chief of Kaiser Health News. “The reasons premiums, deductibles and copayments are going up is because prices are going up,” she says.

A former practicing physician and New York Times health care correspondent, as well as author of the recent book, An American Sickness: How Healthcare Became Big Business and How You Can Take It Back, Rosenthal says in an interview with MONEY that medical prices defy normal market forces. In medicine, for example, competition often drives prices up, not down.

But to some extent, you can control how much you pay for your health care. Here are three strategies Rosenthal recommends for lowering your medical bills:

1. Choose the Right Doctor

courtesy of Penguin Books

Most consumers know to ask whether their doctor takes their insurance or not. But you should also ask whether the practice is owned by a hospital or licensed as a surgery center, Rosenthal says. If the answer is yes, you or your insurer may find yourself on the hook for high “facility fees.” (Even if your insurer picks up the tab, the carrier will eventually pass those increased costs on to you in the form of higher premiums, deductibles, and co-pays.)

Other questions to ask: If you need a referral, would the doctor only refer you to a specialist within your insurance network? Where does the office send blood work or radiology testing? (The prices for blood processing at a hospital can be 100 times more than at a commercial lab, Rosenthal writes, while a bill from an out-of-network radiologist you never met—but who read your scan—can come as a shock.)

2. Question Treatment Decisions

If you have chest pain, shortness of breath, a bad allergic reaction or other urgent symptoms, seek medical care right away, Rosenthal says. But for less pressing ailments, it pays to wait a few days to see if the problem gets better on its own. “Cars don’t get better by themselves, but people do,” she says.

Once you have an appointment, you need to realize that, for medical practices, there’s no money in waiting. For the most part, doctors make money by performing procedures, not by counseling patients to give it a little time. When your doctor does recommend a test or procedure, ask questions.

  • Ask how much it will cost—and don’t accept “it depends on your insurance” for an answer, Rosenthal says. The doctor—or the office’s billing specialist— should be able to give you a price range for your insurer; at minimum, you should be able to get them to tell you the cash price charged by the testing location.
  • Ask how the test/surgery/exam/x-ray would change your course of treatment. If the answer is it probably won’t, then press for why the procedure is needed—and consider skipping if you don’t get a good answer.
  • Ask where any proposed treatment will take place. Doctors often do procedures at different locations on different days of the week. Avoiding your doctor’s days at the hospital could save you big.
  • And ask upfront if anyone else will be involved in your care, in order to avoid surprise medical bills from doctors or other medical providers—some of whom you might never actually meet, particularly if they end up treating you when you’re under anesthesia.

3. Challenge Your Bills

Rosenthal recommends taking one extra step when you’re hospitalized: In the pages of the admitting documents you have to sign, there will be an item on your willingness to accept financial responsibility for charges not covered by your insurer. Before you sign, write next to it, “as long as the providers are in my insurance network.” This will give you a basis for challenging unexpected charges later.

Despite your best efforts, however, you may still receive some outrageous bills. “Prices are so inflated that often even low-level clerks are authorized to approve major discounts,” Rosenthal writes. If you haven’t met your plan’s deductible and are paying out of pocket, make the doctor an offer, she recommends—noting she’s heard from patients who have had bills more than halved on the spot.

Always ask for itemized hospital bills, she notes. Many hospitals group charges under categories like “pharmaceuticals,” when in reality every single pill and piece of surgical equipment carries an individual price. While hospitals sometimes balk at the request, it’s your right to see all of them, Rosenthal says.

Check your bill for errors—which are more common than you’d think—and protest any mistakes or outrageous charges in writing, says Rosenthal. (She includes sample letters in her book.) If you’re disputing a surprise out-of-network bill, check what protections your state offers against them. New York is among handful of states with laws on the books to protect consumers from surprise bills from out-of-network providers. But even if your state doesn’t have one—or you’re in a large-group plan that isn’t covered by your state’s law—you can still reference those laws in your protest letter, Rosenthal says. Consumers Union has an online tool that can be used to find contact information for the insurance department in your state.

The dispute process can take time, Rosenthal cautions. To preserve your credit, let the doctor or hospital know that you’re disputing their bill, and ask that they not send the bill into collections.

Health – TIME

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