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Texas Department of State Health Services

That’s not how you test

Oops.

Texas health officials made a key change Thursday to how they report data about the coronavirus, distinguishing antibody tests from standard viral tests and prompting slight increases in the state’s oft-cited daily statistic known as the positivity rate.

The positivity rate is the ratio of the confirmed cases to total tests, presented by the state as a seven-day rolling average. The Texas Department State of Health Services disclosed for the first time Thursday that as of a day earlier, it had counted 49,313 antibody tests as as part of its “total tests” tally. That represents 6.4% of the 770,241 total tests that the state had reported through Wednesday.

Health experts have warned against conflating the tests because they are distinctly different. Antibody tests detect whether someone was previously infected, while standard viral tests determine whether someone currently has the virus.

Now that DSHS is reporting the number of antibody tests, it has recalculated its daily positivity rates starting Tuesday to exclude such tests. That led to a 0.41 percentage-point increase in Tuesday’s rate and a 0.55 point increase in Wednesday’s rate, according to DSHS calculations.

DSHS acknowledged last week that it was reporting an unknown quantity of antibody tests as part of the “total tests” figure. Despite that, Gov. Greg Abbott incorrectly claimed Monday that the state was not “commingling” the numbers while promising the state would soon break out the antibody test count.

[…]

When public health agencies combine antibody testing figures with viral testing figures, “I want to scream,” said Seema Yasmin, an epidemiologist and director of the Stanford Health Communications Initiative.

Viral tests, usually taken from nasal swabs, can detect an active coronavirus infection. If a person’s biological sample is found to have traces of the virus’s genetic material, public health workers can order them to self-isolate and track down any of their contacts who may have been exposed.

Antibody tests “are like looking in the rearview mirror,” Yasmin said, because they may show if a person has recovered from a coronavirus infection. That can be useful for public health surveillance, but it does not offer much insight about where the virus is currently spreading. Another issue is that many antibody tests have been shown to have high rates of inaccuracy, she said.

“As an epidemiologist, this level of messiness in the data makes your job so much more difficult, and it misleads the public about what’s really happening,” Yasmin said. “We’ve been talking about the capacity for testing increasing over the last few weeks, but now we might have to tell the public that might not be true.”

And dumping antibody testing data into the pool of viral testing data brings the overall positivity rate down, reflecting “a deceptive misuse of the data,” analysts for the COVID Tracking Project wrote last week. That’s because the numbers may make it seem like the state has grown its testing capacity even if a state’s viral testing capacity remains flat.

“This is crucial as we need increased capacity for viral testing before reopening to identify active infections even in the pre-symptomatic or asymptomatic stages,” the analysts wrote.

To be fair, Texas is not the only state to have done this. Florida and Georgia have been accused of manipulating their data in other ways as well. The bottom line here is that we’ll never get our arms around this pandemic if we don’t have good data. The data is messy enough as it is, we surely don’t need to be making it worse.

More reopening

Onward we go, whether wise or not.

Gov. Greg Abbott on Monday announced his next wave of reopenings designed to restart the Texas economy during the coronavirus pandemic, saying child care facilities can reopen immediately, bars can open Friday with limited capacity and sporting events can return without fans at the end of the month.

Abbott also said he would permit restaurants to operate at 50% capacity starting Friday, up from 25% that’s allowed now.

At the same time, Abbott exempted two hotspot regions — Amarillo and El Paso — from his latest decisions, saying they would need to wait a week — until May 29 — while the state’s surge response teams work to contain outbreaks in each area.

Abbott’s news conference came 18 days after he began a phased reopening of the state, starting with letting restaurants, stores, movie theaters and malls open up at 25% capacity. He then allowed barbershops and salons to reopen May 8 under certain restrictions. Monday was the first day gyms were allowed to open up, also under restrictions.

Previously, child care was only available to workers deemed essential by the state. Abbott’s announcement Monday allows child care centers to reopen to help all workers returning to their jobs.

In addition to bars, Abbott is letting a host of other establishments reopen Friday, including bowling alleys, bingo halls, skating rinks, rodeos, zoos and aquariums. In the lead-up to Monday, however, the fate of bars had drawn the most attention, especially after Abbott began allowing restaurants to reopen May 1. All the businesses opening Friday will only be allowed to operate at 25% capacity.

For bars that reopen Friday, the state is recommending that customers remain seated at tables of no more than six people, among other restrictions. Dancing is discouraged.

Insert Baptist joke here. On the one hand, the daily case numbers keep rising, with no clear indication that we were approaching a peak even before we started loosening things up, and without achieving the Abbott-stated benchmark of 30,000 tests per day. It’s not that we’re reopening per se, it’s that Abbott himself laid out conditions and requirements and penalties for people who failed to comply, then dropped it all like a hot rock the minute some grifter hairstylist in Dallas threw a hissy fit. It just doesn’t inspire confidence that Abbott has any idea what he’s doing or any plan to retreat if things start to get worse. That said, the rate of growth in the state is fairly slow, hospital capacity is in good shape – both of these are no doubt helped by the solid results in Harris County, for which Abbott owes Lina Hidalgo a big thank you – and to his credit Abbott paid attention to the places that needed and asked to be excluded from this round of reopenings.

The next round of reopenings will come May 31, when Abbott allow permit summer youth camps to reopen — as well as let certain professional sports to resume without spectators. The sports include basketball, baseball, car racing, football, golf, softball and tennis. Leagues will first have to apply to — and receive approval from — the Texas Department of State Health Services.

[…]

Notably, Monday marked the first time that Abbott singled out specific regions as not ready to take part in the latest reopenings.

Amarillo has been a hotspot due to outbreaks at its meatpacking plants, and earlier this month, the state dispatched one of its Surge Response Teams to the city to try to get things under control. Of the 1,801 new cases that Texas reported Saturday, over 700 were linked to the Amarillo meatpacking plants, according to Abbott’s office.

In El Paso, the situation has deteriorated enough that the county judge, Ricardo Samaniego, and other local officials asked Abbott last week to exempt the county from the next reopenings until the county sees a two-week downward trend in the number of positive cases or positive test rate. Abbott said Monday that El Paso’s hospital capacity is “too close for comfort at this particular time.”

The one-week delay “will give those communities and our surge team response the time needed to slow the spread and maintain hospital capacity,” Abbott said. “It will ensure those communities safely move into phase 2.”

The counties subject to the delay are El Paso, Randall, Potter, Moore and Deaf Smith. The latter four are all in the Amarillo region.

I have my doubts that the Abbott Strike Force will make any difference in these places, unless they find the will to shut down the meatpacking plants that have been such hotspots, but at least he’s not ignoring reality, unlike some other state officials I could name. He’s still wishy-washy, and in the end if this works out reasonably well I’ll believe it’s because he was more lucky than smart, but it could be worse. In this state, that’s often the best you can hope for. The Chron, the Press, the Current, the Rivard Report, and the Dallas Observer have more.

More on coronavirus and meat processing

From the Trib:

To understand powerlessness in a pandemic, trace a northbound path from Amarillo up State Highway 87. Not too far shy of the border where Texas meets Oklahoma lies Moore County.

There are few easy ways to make a living in this country of feedlots and dryland cotton, but one of the hardest is at the JBS Beef meatpacking plant. Just about everything looks small on these vast flatlands until you get right up on it, but the 125-acre plant in the tiny town of Cactus is massive from any vantage point.

The steady billow of gray smoke from the plant’s stacks tells you it is still running full tilt. With the coronavirus pandemic gripping the world, it’s considered essential to keep thousands of cattle running through the kill floor each day, headed for dinner tables across America.

Meat and poultry plants nationwide have emerged as incubators for coronavirus spread. More than a dozen have been forced to shut down temporarily as the number of cases and deaths tied to those facilities rose; others have scrambled to ramp up health and safety precautions in facilities where meatpackers often must work shoulder to shoulder.

State health investigators are tracking 159 coronavirus infections tied to the Cactus plant, including one death associated with the outbreak, and Moore County now has the highest reported infection rate in Texas. Yet about 3,000 workers, mostly immigrants from Mexico and Guatemala and refugees from Asia and Africa, still report there each day.

Meatpacking has always been brutal and dangerous work, but it pays relatively well. JBS jobs have drawn generations of immigrants to this rural community, so many that Hispanics make up more than half of Moore County’s nearly 22,000 residents, and one quarter of the population is immigrants.

But the people who prop up life here, the ones now getting sick or working in fear wondering when they will, have little power over what the coronavirus is doing to their lives, because they have little power here at all.

From the Observer:

Officials at Tyson’s poultry processing plant in Shelby County may have waited weeks to tell workers that an employee had tested positive for COVID-19, preventing other workers from taking action to prevent the spread of the virus inside the facility, plant employees told the Observer last week. The company waited even longer to implement rudimentary safeguards (such as breathing masks and plastic screens to separate workstations) as more workers fell ill, were hospitalized, and died, they say.

[…]

The Observer has changed Bennett’s name, as well as the two other employees named in this story, after employees expressed concern that Tyson might retaliate against them for speaking to a reporter. The story also omits some details of employees’ positions within the plant and their medical histories to make them less identifiable. The extent to which the Tyson outbreak has contributed to COVID cases in this rural region is still unclear, partially because of a lack of reliable state data on infection rates and testing. It is clear, however, that some workers feel as if Tyson put profits over worker safety as the virus spread through the facility this month. If the company had distributed protective equipment earlier, “it probably wouldn’t be as bad as it is now,” Bennett says.

The employees say that approximately three weeks ago, a plant supervisor told workers that at least one employee had tested positive. But they shouldn’t worry, the supervisor reportedly said—the case had occurred two weeks earlier, so other workers likely wouldn’t be threatened. The announcement hit the workers like a bombshell. “I don’t think it was fair to us as employees the way they waited until 14 days later to tell us,” says Denise Richardson, who has not contracted the virus. “If you’ve got paperwork confirming that someone has it, you let everybody know and give us all an opportunity to take proper precautions.” At the time, the company had just recently begun to start screening workers by checking their temperature, and masks had not been widely distributed to employees, Richardson says.

By the time Tyson alerted employees to the danger, the virus already appeared to be spreading. Bennett, after days of “feeling sicker and sicker, weaker and weaker” at work, was hospitalized shortly after the announcement. Bobby Dawson, another Tyson employee, tested positive for COVID-19 about the same time as Bennett. He says he informed plant supervisors about the positive test result the same day he learned of it. Dawson criticized the company for not telling him about the situation sooner, which would have allowed him to take precautionary measures to keep from getting sick, such as taking days off work or wearing protective equipment. “They hid it from us. They didn’t give us a choice to do anything,” Dawson told the Observer. “Their main concern is to get them chickens out, regardless of what their employees are going through. That’s why we all come up sick.”

The conditions of the plant lend themselves to the spread of disease, the workers say. Employees work “elbow to elbow” as they defeather, eviscerate, and debone thousands of birds a day. Even the most innocuous task—such as clocking in for a shift and clocking out at the end of the day—appears to present considerable risk, as hundreds of employees crowd the few functional terminals. “You got so many people trying to clock in at one time you can’t do nothing but catch it,” Richardson says. “We’re packed in there like a bunch of sardines.”

Richardson also notes that many of the plant’s workers cross the border each day from Shelby County’s adjacent parishes in Louisiana, a state that’s been ravaged by the virus. Shelby County shares a border with DeSoto Parish, where at least 180 confirmed cases and 10 deaths have been counted among a population of only 27,000.

See here for the background. These and other meat processing plants will continue to stay open due to federal order. I don’t have anything to add here, just that you should go read both of these stories.

And so reopening begins

I have questions.

Gov. Greg Abbott said Monday that he will let the state’s stay-at-home order expire Thursday as scheduled and allow businesses to begin reopening in phases the next day, the latest ramp-up in his push to restart the Texas economy amid the coronavirus pandemic.

First to open Friday: retail stores, restaurants, movie theaters and malls. But they will only be allowed to operate at 25% capacity. Museums and libraries will also be allowed to open at 25% capacity, but hands-on exhibits must remain closed.

Abbott said a second phase of business reopenings could come as soon as May 18 — as long as the state sees “two weeks of data to confirm no flare-up of COVID-19.” That second phase would allow business to expand their occupancy to 50%, according to the governor.

Abbott made the announcement during a news conference at the Texas Capitol, which he began by saying he would let the stay-at-home order expire because it “has done its job to slow the growth of COVID-19.” While the spread of the virus in Texas has slowed down throughout April, the number of cases is still increasing day to day, and it is unclear if the state has yet seen its peak.

“Now it’s time to set a new course, a course that responsibly opens up business in Texas,” Abbott said, flanked by Lt. Gov. Dan Patrick and Texas House Speaker Dennis Bonnen. “Just as we united as one state to slow COVID-19, we must also come together to begin rebuilding the lives and the livelihoods of our fellow Texans.”

Abbott said his new order “supersedes all local orders” saying those businesses must remain closed. He also said his order overrules any local government that wants to impose a fine or penalty for not wearing a mask — something the latest statewide rules encourage but do not mandate.

Speaking shortly after Abbott in Houston, the city’s mayor, Sylvester Turner, told reporters that Abbott’s new order “pretty much will take these measures, the ability to [issue] stay-at-home orders and things of that nature, out of our hands locally.” He said he hoped Abbott’s plan works but offered a “cautionary note,” pointing out that there is still no vaccine and statistics show the “virus is still here,” even as local measures have slowed it down.

Abbott stressed that his order “gives permission to reopen, not a requirement,” and businesses can stay shuttered if they would like.

At the same time, Abbott said he is holding off on reopening certain businesses for the time, including barbershops, hair salons, bars and gyms. He said he hopes those businesses can open “on or no later than mid-May.”

[…]

Abbott mostly focused Monday on contact tracing, or the practice of tracking down and isolating all the people someone who tested positive for the virus has come into contact with. Abbott said Texas is already in the second phase of its contact tracing plan, adding 1,000 tracers on top of the existing 1,100 and launching a statewide app and call center to improve the process.

Abbott continued to talk of a coming increase in testing and said the state soon would “easily exceed our goal of 25,000 tests per day.” The state has been adding an average about 14,000 tests per day over the past week, according to figures from the Texas Department of State Health Services. Still, the total number of tests done as of Monday — 290,517 — remained about 1% of Texas’ nearly 29 million people.

See here for the background, and here for the plan, such as it is. It’s full of guidelines for various businesses and customers and nursing homes and the like, and short on details about things like how we’re going to achieve the testing goal. If you haven’t yet started wearing a face mask you don’t have to, though you really should and in some places you won’t have a choice regardless of what Abbott says.

I said I have questions, so here are a few:

– How many businesses will consider it worth the bother to reopen at 25% capacity?
– What does “confirm no flare-up of COVID-19” mean? As the story notes, the daily number of cases is continuing to rise. If two weeks from now that is still the case, but the rate of the daily increase hasn’t gone up, is that a success under the Abbott plan?
– What happens if there’s a local “flare up”, like say at another meat processing facility, or just in some random part of the state? If Montgomery County has seen an uptick in cases, do they get to re-impose a shutdown order?
– When should we expect to see that statewide app? Will it require some minimum number of people to download and install it in order to work? What metrics will there be for it – number of app downloads, number of people traced, number of infections mapped out, etc? What happens if we fail to meet those metrics?
– What medical experts advised on this? Because clearly not all medical experts are in agreement with it.

I don’t know the answer to these questions. I doubt Greg Abbott knows the answer to most of them. As I said before, the word that comes to mind for this is “half-baked”. Maybe everything will be fine, maybe we’re just easing up on less-risky behavior, maybe that testing and contact tracing regimen will be more robust than I expect, maybe people will continue to take social distancing seriously enough to keep a lid on things. I hope everything does go well. I’d surely like to start going places and doing things again. I’m just concerned that we barely have a Plan A, let alone a Plan B. What will we do if this doesn’t go the way we hope? The Current, the Press, the Rivard Report, and the Chron have more.

Coronavirus and meat processing

In the Panhandle:

State health officials confirmed Tuesday that they are investigating an outbreak of the new coronavirus at the JBS Beef packing plant in the Texas Panhandle, part of ongoing efforts to monitor major meat processing plants as the pandemic continues to threaten food supply chains.

Earlier this month, the Department of State Health Services conducted an epidemiological investigation in Shelby County that identified a cluster of 14 coronavirus cases and two related deaths that were “in some manner” tied to employees of a Tyson Foods facility.

Now, a department spokeswoman said, an “environmental assessment team” is being sent to Moore County to advise on ways the massive meatpacking plant, which processes a significant portion of the nation’s beef, can curb the spread of COVID-19, the disease caused by the new strain of the coronavirus.

The investigation follows the shuttering of the company’s meat packing plants in other states because of local outbreaks. Moore County, near the Oklahoma border, has one of the highest rates of infection per capita in the state. (Some local leaders attribute it to rapid testing.)

After a call with Tyson Foods officials, the health department asked the company to enact additional protections for employees at its facility near the Louisiana border, including monitoring all individuals entering the facility for both fever and other COVID-19 related symptoms, and to increase its sanitizing as part of the transportation the company provides for workers.

And in East Texas:

The state health department is investigating cases at a Tyson poultry processing plant in Shelby County that may comprise a significant number of the county’s 69 confirmed cases. While meatpackers across the nation have been slammed with high numbers of coronavirus cases, leading to the deaths of workers and facility closures, this represents one of the first known outbreaks of the virus at a plant in Texas.

The Texas Department of State Health Services (DSHS) has offered few details of its investigation into the outbreak at the Tyson facility on the Texas-Louisiana border. But Dr. Florencio Singson, who operates a clinic in Center, the county seat, told the Observer that health officials said the outbreak represents a “majority” of the county’s cases. Meanwhile, Tyson posted on its Facebook page that it is closing the facility this week. The post made no mention of the apparent outbreak, saying only that the company was installing new equipment at the plant.

Shelby County, population 25,400, has one of the highest per capita rates of confirmed COVID-19 cases in Texas. It’s nearly four times that of the state overall, and the highest countywide rate outside the Panhandle. Cases ballooned in Louisiana and into East Texas in recent weeks, with coronavirus now confirmed in nearly every Texas county in the region, many of which are rural and have limited medical resources. Many also have large populations of African Americans, who are being infected with and dying of coronavirus at disproportionately high rates.

Public health experts say the spread of coronavirus in the region (and the state overall, which had nearly 20,200 confirmed COVID-19 cases as of Tuesday evening) is likely dramatically undercounted due to limited testing. “We know it’s underreported [in Shelby County],” Singson told the Observer. Texas has been slow to roll out widespread testing, resulting in among the fewest completed tests per capita of any state.

As the Observer story notes, COVID-19 outbreaks have occurred at meat processing plants around the country, with the Smithfield outbreak in South Dakota being the worst so far. It’s not a surprise – workers are in close proximity, and there has been little done by their employers to keep them safe, which is typical for an industry that generally treats its employees terribly. Smithfield had the benefit of a union – you can listen to a short conversation with the local labor council president for Sioux Falls here if you want to learn more about that location – but it wasn’t enough. I can’t imagine the workers in Texas, at either location, having it any better. You want to know what’s in the future when and if we “reopen the economy” without a real plan and real resources for universal testing and worker protection, there you have it.

By the way, the city of Cactus, where the JBS plant is, is under an executive order requiring “everyone over the age of five” to “wear a covering over their mouth and nose when outside their home or vehicle”, with violators subject to a fine of up to $1,000. Sound familiar? Moore County voted 75% for Donald Trump in 2016. I’m just saying.

Treating COVID-19 patients at nursing homes

This is a huge can of worms.

When Larry Edrozo got a phone call from his mother’s nursing home in Texas City telling him she was being treated for the novel coronavirus with an unproven pharmaceutical drug, he had two questions: why was she getting the drug if she had not been showing symptoms, and who gave consent?

Helen Edrozo, 87, is one of 56 residents at the Resort at Texas City who tested positive for the coronavirus, and one of 39 residents being medicated with hydroxychloroquine, a drug typically used to treat malaria and lupus that has shown some evidence of possibly tamping down symptoms of the virus.

The use of hydroxychloroquine to treat coronavirus patients has drawn controversy globally as the medical community and public debate the ethics of testing a medication before significant research is available — and in the case of elderly patients such as those at The Resort at Texas City, on a population that is statistically more vulnerable to the virus. While President Donald Trump has touted the drug’s benefits, a large controlled study of hydroxychloroquine has not yet been completed, and some doctors warn the drug combination used for the experimental treatment could have severe, potentially deadly side effects.

Larry Edrozo was initially told by an administrator at the nursing home that Helen would not eligible for hydroxychloroquine treatment because she was not showing symptoms. But on Monday, a nurse at the facility phoned him to tell him that his mother’s carbon monoxide levels in her blood had elevated slightly and that she had already begun a hydroxychloroquine dose.

Edrozo was stunned. His mother has dementia, meaning that, as her power of attorney, he is supposed to sign off on any medical treatment she receives at the nursing home.

“I (told the nurse), ‘OK, well, since you’ve already started (treatment), I guess I would write in my notes that the question was raised about consent and what happened to that?’” Edrozo said. “I have not received a call back.”

Dr. Robin Armstrong, the medical director at The Resort, who prescribed the medication shortly after Amneal Pharmaceuticals donated 1 million tablets to the Texas Department of State Health Services pharmacy, said the decision was between him and his patients. He said he did not notify families before the drugs were administered because it was not necessary and time consuming.

“If I had to call all the families for every medicine that I started on a patient, I wouldn’t be treating any patients at all; I would just be talking to families all the time,” Armstrong said

But ethicists say informed consent is one of the most important factors in any treatment, and several people with family members at the Resort at Texas City being treated with hydroxychloroquine say that they were not asked to give consent, despite having power of attorney over their sick relatives.

Still, faced with the desperation of potentially losing his mother to the coronavirus, Edrozo felt he had no other choice than accept this course of treatment.

“When the people are blasting the doctors and the governor’s office about human guinea pigs, I’m sort of there with them,” Edrozo said. “But then I want to ask them, ‘What if it was your mother, or your spouse or your child?’”

As the kids say, there’s a lot to unpack here. At the most basic level, there’s nothing but anecdotal evidence that hydroxychloroquine has any effect on coronavirus. There are no studies worthy of the name showing that it would help. Maybe it will, maybe it won’t, we just don’t know. And that’s without taking into account the inability of these patients on whom the tratment is being tested to give informed consent for their participation. Or the fact that hydroxychloroquine is an actual drug used by people suffering from lupus and malaria, and Donald Trump’s obsession with it as an unproven treatment for COVID-19 means potential shortages for those patients. Did I mention that the doctor leading this effort is a Republican activist who got a supply of the drugs through political connections, and who therefore has a vested interest in making Trump and his hydroxychloroquine predictions look good? All this, and even if it does help some of these patients it won’t tell us anything about the effectiveness of hydroxychloroquine as a treatment because this isn’t a controlled study. Keep in mind, everyone who has recovered from COVID-19 has done so on their own. We’ll have no way of knowing whether the people at The Resort who recover would have done so anyway – that’s why doing controlled studies matter, so you can make valid comparisons. I very much get Larry Edrozo’s dilemma, but he and everyone else involved in this deserved to have full knowledge of the risks and benefits so they could make their own decision.

We still have no idea how many people have been infected

There’s just a real lack of testing being done.

Six times in three weeks, Marci Rosenberg and her ailing husband and teenage children tried to get tested for the new coronavirus — only to be turned away each time, either for not meeting narrow testing criteria or because there simply were not enough tests available.

All the while, the Bellaire family of four grew sicker as their fevers spiked and their coughs worsened. They said they fell one by one into an exhaustion unlike any they had felt before.

By March 18, Rosenberg was desperate and pleaded with her doctor for a test. Dr. Lisa Ehrlich, an internal medicine physician, told Rosenberg to pull into her office driveway. But Ehrlich warned Rosenberg, “I can only test one of you.” She swabbed her throat through an open car window. The result came back the next day: positive.

The rest of her family was presumed to be positive but untested – and thus excluded from any official tally of the disease.

As the number of confirmed cases of the potentially deadly virus continues to explode across the Houston region – tripling from 1,000 to more than 3,000 in just the past week – there is mounting evidence that the true scope of the disease here could be far worse than the numbers indicate.

A Houston Chronicle analysis of testing data collected through Wednesday shows that Texas has the second-worst rate of testing per capita in the nation, with only 332 tests conducted for every 100,000 people. Only Kansas ranks lower, at 327 per 100,000 people.

In cities across Texas — from Houston to Dallas, San Antonio to Nacogdoches — testing continues to be fraught with missteps, delays and shortages, resulting in what many predict will ultimately be a significant undercount. Not fully knowing who has or had the disease both skews public health data and also hampers treatment and prevention strategies, potentially leading to a higher death count, health care experts say.

[…]

As the pandemic’s march quickened, Texas was slow to ramp up testing.

The first confirmed case in Texas, outside those under federal quarantine from a cruise ship, was March 4, striking a Houston area man in his 70s who lived in Fort Bend county and had recently traveled abroad. By month’s end, the Houston area had more than 1,000 confirmed cases. A week later, the number had pushed past 3,000.

Yet it was not until March 30 that the rate of testing per 100,000 people in Texas topped 100. As of Wednesday, the state was testing 327 per 100,000, according to a Chronicle analysis of data from The COVID Tracking Project, which collects information nationwide on testing primarily from state health departments, and supplements with reliable news reports and live press conferences.

Twenty-six states in the U.S. are testing at least double the number of patients per capita as Texas, in some cases six times more. New York, for instance, is testing 1,877 per 100,000 people while neighboring Louisiana is testing 1,622 per 100,000. Even smaller states, such as New Mexico, are testing triple the rate of Texas.

Texas officials defended the state’s response.

“We’ve consistently seen about 10 percent of tests coming back positive, which indicates there is enough testing for public health surveillance,” said Chris Van Deusen, a spokesman for the Department of State Health Services, in an email, “If we saw 40 or 50 percent or more of test coming back positive, we’d be concerned that there could be a large number of cases out there going unreported, but that has not been the case.”

It is unclear if that is a reliable measure. Nearly 41 percent of New York tests were positive, the second-highest rate in the country. In Texas, about 9.4 percent of tests were positive — roughly the same as Washington state, where one of the largest outbreaks of coronavirus has occurred.

Not the first time we’ve talked about this, and it won’t be the last. This also means that the official number of deaths attributed to coronavirus is likely too low. This has been the case globally, especially in the hardest-hit places, where the difference between the normal daily mortality rate and the observed mortality rate during the crisis is a lot bigger than the official count of COVID-19 deaths. The good news is that as yet our hospitals have not been overwhelmed, but we can’t say with confidence that that will continue to be the case.

The number of people hospitalized with COVID-19 in the Houston area is continuing a steady climb, not close to crisis levels but unnerving enough that experts still aren’t sure when the area’s grand experiment in social distancing will start showing up in daily counts.

After a week in which COVID-19 hospitalization numbers more than doubled in Harris County, epidemiologists and infectious disease specialists said it likely will be another week to 10 days before they know if the stay-at-home orders and closures are reducing the rate at which the coronavirus is spreading and keeping health care facilities from being overwhelmed.

“Even though we’ve been social distancing for three weeks, it’s too early to know when we’ll be on the downward slope,” said Catherine Troisi, a professor of epidemiology at UTHealth School of Public Health. “The numbers we’re seeing now reflect people who were exposed to the virus up to four weeks ago.”

Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine and Texas Children’s Hospital, said the social distancing has paid off in terms of keeping hospital volumes under control so far but added that the pay-off in terms of ending the pandemic is unclear. He said that “we need to continue stay-at-home orders until the end of the month, then reassess whether to extend them longer.”

Hotez and others said that aggressive social distancing is more important now than ever, given modelers are projecting that the number of COVID-19 cases in the Houston area should peak in the next few weeks. They said people venturing out during the peak period will put themselves at high risk of contracting the virus.

[…]

The study, released on March 24, originally said the virus’ spread in the Houston area would peak April 7 and burn out by mid-May if stay-at-home orders are continued until May 12. It was not clear Tuesday when the study projects the virus will burn out now.

Eric Boerwinkle, the lead researcher, could not be reached for comment Tuesday and UTHealth officials had no update on the study. Boerwinkle, who did not make the original modeling publicly available, has briefed top local government officials on the work.

Another modeling study, conducted by the University of Washington’s Institute for Health Metrics and Evaluation, now projects that the Texas peak use of hospital resources for COVID-19 will be April 19, some two weeks earlier than it previously projected. The study, reportedly relied on by the Trump administration, foresees no bed shortage in the state, including in intensive care.

“That’s why you shouldn’t place too much weight on any one model,” said Dr. James McDeavitt, Baylor’s dean of clinical affairs. “They depend on assumptions plugged in and can show everything from Houston being able to handle the surge to a New York City-like situation.”

McDeavitt noted the wild cards that go into modeling — the number of people admitted to a hospital, the percentage that need intensive care, how long it takes to get patients off ventilators, how long they need to recover in a regular bed once they move out of intensive care. Those are the assumptions that drive models, he noted.

McDeavitt said he doesn’t think the number of cases will come down in the Houston area until the end of the month.

That story was from earlier in the week, so all of the numbers are a bit out of date by now. But the bottom line remains that we don’t know where we are on the curve because we don’t really know how many people are or have been sick. Models all rely on data, and we’re also not good with the data.

The information Texans are working with is too damn thin.

Where to start? Not enough tests have been completed, or taken, to really know who has or doesn’t have the disease, where the Texas hotspots are, or whether people who have died of respiratory problems had COVID-19. The relatively small number of test results also means we don’t know which people had the disease and recovered (and how many people have recovered) and whether the projections being made with that skimpy data are accurate enough to guide our public health decisions.

It’s not enough to say that the testing is getting better, that we know more than we knew just a few days ago. What we still don’t know overshadows what we do know.

We’re like pilots flying in clouds without instruments. We know a little bit, but not enough to make really solid decisions or to figure out what’s next. We’re learning as we go. As of Thursday, Texas was reporting 10,230 cases and 199 deaths, 1,439 hospitalized COVID-19 patients and 106,134 tests conducted.

Given the level of testing right now, it’s hard to know how many cases Texas really has. Because the best way to get tested for the new coronavirus is to show symptoms that a medical professional finds troublesome, it’s probably safe to say we’re not testing many people who are carrying the virus but don’t have symptoms.

It’s easier — because it’s more obvious — to map the institutional cases. When someone in a nursing home or a state supported living center or a prison tests positive, testing everyone in that location is simple and smart. It’s simple to figure out that everyone in a given building or campus might have been exposed.

Even that data isn’t always available. The state of Texas initially wasn’t sharing details about the data it has collected from nursing homes where COVID-19 cases have been found. But a few days after The Texas Tribune’s Edgar Walters and Carla Astudillo wrote about it, the state revealed 13% of nursing homes have at least one confirmed case.

We’re doing a lot of flying blind. If we want to make good decisions about things like when and how to restart the economy, we need a much better understanding of where we are, and where that means we’re likely to be going.

We don’t really know how many COVID-19 patients there are in Texas hospitals

For a variety of reasons, the data is hard to get a handle on.

Be like Hank, except inside

Texas is bracing for a pandemic that is projected to kill tens of thousands of people across the U.S., but health officials and state leaders are struggling to provide the public with timely updates on how many people are infected and how many hospital beds and ventilators are available for the critically ill.

Other states across the country have been providing coronavirus hospitalization figures for weeks. On Friday, Gov. Greg Abbott announced that 827 people have been hospitalized in Texas. But the true number of cases is likely far higher than the official tally due to a shortage of reliable tests and delays in delivering results, which can take up to 10 days.

Even with the limited number of confirmed positives, Harris County’s top epidemiologist says it feels like her team is constantly behind.

“It’s become overwhelming,” said Dr. Dana Beckham, director of the county’s Office of Science, Surveillance and Technology, which traces the steps of people who test positive for COVID-19 to determine how they got the disease and who they may have infected. “We’re always behind the eight ball.”

The county’s epidemiologists were pulling 12-to-16-hour days, seven days a week and they still couldn’t keep up, Beckham said. They brought in more workers – roping in other county government employees and hiring outside contractors – to prevent burnout and alleviate stress, tripling the number of people working in the unit to about 65.

It’s still not enough, she said.

As health officials scramble to mitigate the worst pandemic in generations, the level of detail released by Texas lags behind that of some counties and cities.

The Texas Department of State Health Services publishes a daily update of the official number of confirmed coronavirus cases — there were 5,330 statewide as of Saturday and 90 deaths. But the agency doesn’t routinely publish other key measurements that could show the potential for strain on Texas’ health care system in the coming weeks.

[…]

The 827 hospitalized coronavirus patients in Texas are confirmed COVID-19 cases — not suspected cases in which patients are exhibiting symptoms but have no test results, said Chris Van Deusen, a spokesman for DSHS.

Front-line health care workers in the Houston area have told the Houston Chronicle that many patients who should be tested and hospitalized are slipping through the cracks. They also worry that patients admitted with other conditions, such as a heart attack, who also are showing symptoms of the virus may not show up in overall counts.

Unconfirmed COVID-19 cases are likely taking up a significant number of hospital beds. According to the Southeast Texas Regional Advisory Committee, an organization tasked with tracking medical resources in Houston and the surrounding area, as of Thursday more than 700 patients with COVID-19 symptoms — which includes confirmed and suspected cases — had been hospitalized in Harris County alone.

More than 240 were being treated in intensive care units in the county, which has about 4.7 million residents. There were 480 patients on ventilators as of Thursday and 684 additional ventilators were available.

“Currently, we do not have any hospitals reporting that they are nearing capacity,” Darrell Pile, SETRAC’s chief executive officer, told the Chronicle in an email. “Available beds can actually rise if a hospital opens a closed wing, or opts to use beds in the recovery room or other specialty areas to care for inpatients.”

Van Deusen said the state health department had initially collected statistics on suspected cases from hospitals, but by Tuesday had only received reports on 629 patients statewide, raising questions about the accuracy of the state’s figures.

“Hospitalization reporting is a work in progress, and we’re definitely still refining the process,” Van Deusen said.

There’s too much to summarize, so I’d advise you to read that story and also this story about why the official reported numbers of COVID-19 cases in Texas is likely an order of magnitude too low. We’re not doing much testing, which means we can’t really track where the disease is trending, and we’re really just guessing about our hospital capacity and the potential for it to be overwhelmed. We can’t really tell if the local stay-at-home orders, which are now two weeks old, or the previous orders closing schools and canceling public events, which are coming up on four weeks’ duration, have had any effect on flattening the curve. The peak of the outbreak is likely still three or four weeks from now, so whatever the numbers are today, they are going to be a lot higher in the near future. That best-case IHME study Abbott is touting projects four to five thousand deaths in Texas; as of Sunday the official count was 127. That count is also likely low, for the same reasons – not everyone who needs it is getting tested, COVID-19 may be one of several causes of death but not the “official” one, etc – but the point is, we’re barely on the upswing of the curve. We have a lot of staying at home yet to do.

The state responds to coronavirus

Like it or not, we need to be prepared.

Texas officials are scrambling to remain prepared for a major outbreak of a pneumonia-like disease whose global spread one expert says is now moving into “the next phase.”

From the governor’s office to hospitals to state agencies, Texas officials are intensifying efforts to plan for scenarios that could unfold now that the coronavirus is no longer relatively contained to China and surrounding countries and the number of cases is soaring in countries in Europe and the Middle East.

“I think we need to call an audible,” said Peter Hotez, an infectious disease specialist at Baylor College of Medicine and Texas Children’s Hospital. “We need to refresh the algorithms about who’s at risk and when we should suspect someone has the virus. We’re not calling it an epidemic yet, but we should start operating as if it were.”

Hotez said the disease’s spread — the number of cases in Italy and Iran, now about 900, more than doubled in two days, for instance — has made basing screening on the individual’s travel history less relevant. He also noted some recent cases have been characterized by gastrointestinal symptoms rather than respiratory symptoms.

[…]

There are 10 patients with the coronavirus in Texas, including six confirmed by the CDC and four who tested positively in Japan but whose results have not yet been confirmed by the U.S. agency. Of the 10, two came from Wuhan on a State Department-chartered flight and eight came from the Diamond Princess cruise.

There are 15 cases in the U.S. — none in Texas — that weren’t imported.

But CDC officials warned this week that it’s a matter of “when, not if” the virus arrives in the U.S. in larger numbers. The officials said people should start preparing for significant disruptions to daily life.

Noting the alarm that caused in some people who rushed out to buy water or face masks, Dr. Umair Shah, executive director of the Harris County Public Health Authority, said the remarks glossed over the timeline at which the U.S. cases are likely to significantly ramp up. He said that likely won’t be soon.

“The containment strategy in China was effective for giving everyone more time to prepare for the virus,” said Shah, noting the realistic hope was always to delay the virus’ spread, not stop it. “Governments were able to get information out and alert people to be on guard, just as they should be for the everyday flu.”

Three basic things: One, don’t panic. Two, be extra careful about what you read and especially what you share regarding coronavirus. Don’t be one of those idiots who passes along rumors and lies because you couldn’t be bothered to do a little vetting first. And three, practice good hygiene. Cough and sneeze into your elbow, wash your hands frequently, and if you do get sick, stay home. We can all do our part to make a difference.

The extraordinary danger of being pregnant and uninsured in Texas

So utterly appalling.

Right there with them

From 2012 through 2015, at least 382 pregnant women and new mothers died in Texas from causes related to pregnancy and childbirth, according to the most recent data available from the Department of State Health Services; since then, hundreds more have likely perished. While their cases reflect the problems that contribute to maternal mortality across the United States — gross medical errors, deeply entrenched racism, structural deficiencies in how care is delivered — another Texas-size factor often plays a significant role: the state’s vast, and growing, problem with health insurance access.

About one in six Texans — just over 5 million people — had no health insurance last year. That’s almost a sixth of all uninsured Americans, more than the entire population of neighboring Louisiana. After trending lower for several years, the Texas rate has been rising again — to 17.7% in 2018, or about twice the national average.

The numbers for women are even worse. Texas has the highest rate of uninsured women of reproductive age in the country; a third were without health coverage in 2018, according to a DSHS survey. In some counties, mainly along the Mexico border, that estimate approaches 40%.

Public health experts have long warned that such gaps can have profound consequences for women’s health across their lifespans and are a critical factor in why the U.S. has the highest rate of maternal deaths in the developed world. Texas’ maternal mortality numbers have been notably troubling, even as errors in key data have complicated efforts to understand what’s going on and led skeptics, including the governorto question whether there’s really a crisis.

Hardly anyone outside the policy world has taken a deep look at how these insurance gaps play out for women in the second-largest state in the U.S. — at how, in the worst-case scenarios, lack of access to medical care endangers the lives of pregnant women, new mothers and babies.

ProPublica and Vox have spent the last eight months doing just that — combing through government data and reports, medical records and research studies, and talking with scores of women, health care providers, policymakers and families of lost mothers around the state. We learned about Rosa Diaz and dozens of others, mostly women of color, by scouring medical examiner’s databases for sudden, “natural” deaths, then inspecting investigator and autopsy reports for clues about what went wrong.

The picture that emerges is of a system of staggering complexity, riddled with obstacles and cracks, that prioritizes babies over mothers, thwarts women at every turn, frustrates doctors and midwives, and incentivizes substandard care. It’s “the extreme example of a fragmented system that cares about women much more in the context of delivering a healthy baby than the mother’s health in and of itself,” said Eugene Declercq, professor of community health sciences at Boston University School of Public Health.

Most of the mothers whose cases we examined were covered by Medicaid for low-income pregnant women, a state-federal health insurance program that pays for 53% of the births in Texas, more than 200,000 a year, and 43% of all births nationwide. In Texas, the program covers OB-GYN visits, medications, testing and nonobstetric care, from endocrinologists to eye exams.

But the application process is so cumbersome that women in the state have the latest entry to prenatal care in the country, ProPublica and Vox found. It can take months to be seen by regular providers and even longer to access specialists. This poses the greatest danger for high-risk mothers-to-be — as many women on Medicaid are, having had no medical care for significant parts of their lives. Then, roughly two months after delivery, pregnancy Medicaid comes to an end, and the safety net gives way to a cliff. For many new mothers, the result is a medical, emotional and financial disaster.

More than half of all maternal deaths in the U.S. now occur following delivery, according to the Centers for Disease Control and Prevention, with as many as 24% happening six or more weeks after a woman gives birth. In Texas, the proportion of late-postpartum deaths is closer to 40%, with black women bearing the greatest risk. “To lose health care coverage really has a tremendous potential to worsen outcomes,” said Dr. Lisa Hollier, chief medical officer for obstetrics and gynecology for Texas Children’s Health Plan and chair of the state’s maternal mortality review committee.

This is a long excerpt, but there’s a lot more to the story, so please read the whole thing. There are numerous policy decisions at fault here – not expanding Medicaid, low Medicaid reimbursements, cutting off Planned Parenthood and substituting in wholly inadequate alternatives, and more – and all of them can be laid at the feet of the state’s Republican leadership. Whoever runs against Greg Abbott and Dan Patrick and Ken Paxton in 2022 should loudly and repeatedly assert that every maternal death in Texas is their fault. I keep saying this, and it keeps being true: Nothing will change until we have different, and better, government in this state. There’s no other way to do it.

“I’m haunted by their eyes”

We should all be haunted, and outraged, by this.

Immigrants held in a McAllen-area U.S. Customs and Border Patrol processing center for migrants — the largest such center in America — are living in overcrowded spaces and sometimes are forced to sleep outside a building where the water “tastes like bleach,” according to an attorney who recently interviewed some of the migrants.

“It was so bad that the mothers would save any bottled water they could get and use that to mix the baby formula,” attorney Toby Gialluca told The Texas Tribune on Saturday.

But when she recalls the conditions described to her by the immigrants she interviewed at McAllen’s Centralized Processing Center, Gialluca said she goes back to one thing.

“Their eyes. I’m haunted by their eyes,” Gialluca said.

Gialluca and a slew of other lawyers have been meeting with children and young mothers at facilities across the state this month as pro bono attorneys. At the McAllen Center, Gialluca said everyone she spoke with said they sought out Border Patrol agents after crossing the Rio Grande so they could request asylum.

Gialluca said the migrants, all from Honduras, Guatemala, and El Salvador, told her they aren’t receiving proper medical care and children don’t have enough clean clothes. Unable to clean themselves, young mothers reported wiping their children’s runny noses or vomit with their own clothing, Gialluca said. There aren’t sufficient cups or baby bottles, so many are reused or shared.

“Basic hygiene just doesn’t exist there,” Gialluca said. “It’s a health crisis … a manufactured health crisis,” she said.

[…]

On Saturday, state Sen. Carol Alvarado, D-Houston, issued a letter to the Texas Health and Human Services Commission inquiring about the reportedly inhumane conditions at a Clint facility where another group of lawyers told the Associated Press about a group of 250 infants, children and teens who spent nearly a month without adequate food, water and sanitation.

Attorneys who visited the El Paso-area station said they found at least 15 children sick with the flu and described a sick and diaperless 2-year-old boy, whose “shirt was smeared in mucus,” being taken care of by three girls all under 15.

“HHSC has a responsibility to these children and individuals to ensure they are receiving, at a minimum, basic care,” Alvarado wrote, acknowledging that the facilities are managed at a federal level, but still imploring the state to do more. “As these facilities are in our state, the conditions under which they operate is a reflection of our values and commitment to the humane treatment of all within our borders.”

There are a lot of elected officials in this state who support passing laws greatly restricting access to abortion because they say they believe in the sanctity of life. Most of those same officials oppose laws that grant equal treatment under the law to LGBTQ people, and support laws that allow “sincerely held religious beliefs” to be a legal reason to not do business with LGBTQ people, because they believe that LGBTQ people are engaged in immoral behavior. These same elected officials, who care so much about life and morality, don’t have so much as an unkind word to say about the appalling, inhumane treatment of thousands of people, many of them children and babies, right here in Texas. I don’t know why any moral authority is granted to these officials, whose names include Greg Abbott, Dan Patrick, Ken Paxton, John Cornyn, Ted Cruz, Chip Roy, Dan Crenshaw, Ron Wright, Lois “Bathroom Bill” Kolkhorst, Jonathan “Former Fetus” Stickland, Tony “Death Penalty For Abortion” Tinderholt, and many many more. They have clearly shown that they don’t deserve it.

UPDATE: In addition to voting all of these useless assholes out of office, you can donate to or volunteer for any of these organizations if you want to help do something about this.

Our vaccine exception rates keep going up

A small change to the law in 2003 has had a big effect over time.

As measles cases hit a 25-year high in the United States, Texas medical experts fear the state could see the next outbreak of a vaccine-preventable disease. Texas has reported 15 confirmed cases of measles so far in 2019, six more than in all of 2018.

Health officials are watching pockets of Texas closely because of the number of parents requesting exemptions under Texas’s broad vaccine exemption law. Texas is one of 16 states that allow parents to bypass vaccine requirements for enrolling their kids in school by claiming a conscientious exemption, along with citing medical or religious concerns. Just last month, Washington ended conscientious exemptions on the heels of a large measles outbreak with over 70 reported cases. Three states — California, West Virginia and Mississippi — only allow medical exemptions.

Texas’ exemption law used to be stricter. In 2003, a state senator proposed loosening restrictions via a three-page amendment to a 311-page bill. After five minutes of discussion, the amendment was approved. The bill was soon signed into law. Sixteen years later, former state Sen. Craig Estes said the change to Texas’ vaccine laws that he helped enact should be reviewed in the current public health climate.

“Obviously we didn’t ever imagine what would happen,” Estes, a Republican from Prosper, told The Texas Tribune. “With what’s happened recently, I would encourage the legislature in the future to revisit that issue and debate it.”

The speedy way in which the Texas Legislature weakened the state’s vaccine exemption rules suggests that, like Estes, few in office at the time thought it would put Texas at risk for future outbreaks. However, while experts suggest Texas is now vulnerable, efforts to change the exemption law have been dead on arrival in the Capitol.

“There will be a terrible measles epidemic in Texas, and children will be hospitalized in intensive care units, just like they are in New York right now,” Dr. Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine, said last month. “That will wake up the state Legislature to realize that there’s a problem and close those exemptions.”

Kindergarteners must have 10 immunizations to be enrolled in Texas schools. Since 2006, when the state first started reporting the data, the exemption rate for kindergarteners in Texas has risen from 0.3% for the 2005-06 school year to 2.15% for the 2018-19 school year.

In Texas, school districts, private schools and charter schools are required to report their vaccine exemption rates per vaccine. The data collection is done through a survey administered by the Texas Department of State Health Services, but some schools don’t report consistently, leaving gaps in the data.

The data shows certain communities — like the Dallas Independent School District — have seen a recent spike in conscientious exemptions for kindergarteners. Others — like El Paso ISD — have seen exemptions recently plummet. Some smaller private schools, meanwhile, have exemption rates that are significantly higher than those of other schools. The Austin Waldorf School had the highest vaccine exemption rate for the 2018-19 school year, at 52.9%. Alliance Christian Academy had the second-highest rate at 40.6%.

When enough of a community is immunized against a disease, that group has what’s known as herd immunity, meaning there is a low risk of a disease spreading. Vaccine-preventable disease have different herd immunity thresholds. Measles, which is highly contagious, has a high herd immunity threshold of 95%. According to a state report for the 2018-19 school year, Texas kindergarteners statewide had coverage levels higher than 95% for all required vaccines. Yet the data from individual school districts and private schools suggests that some communities may fall short of meeting that threshold for some vaccines.

The fact that a Waldorf school is atop this list shows the problem is very much bipartisan, though the main anti-vax legislators these days are all Republicans. I’ve repeated this a million times, but the only way to improve things is to throw those anti-vax legislators out of office. Next year is a great opportunity to do that as three of them – Jonathan Stickland, Bill Zedler, and Matt Krause – all had close elections in 2018. The rest is up to us. Now go read the rest of the story for the history of how we got to this point.

Pickle ’em if you got ’em

A victory for home foodies.

Sen. Lois Kolkhorst

In a victory for home cooks across Texas, the Legislature has expanded the state’s definition of the word “pickle,” allowing for pickled beets, carrots and other produce to be easily sold at farmers’ markets alongside pickled cucumbers.

The legislation, pushed by state Sen. Lois Kolkhorst, R-Brenham, and state Rep. Eddie Rodriguez, was passed by the House Tuesday and given final approval by the Senate Thursday. It still needs a signature from Republican Gov. Greg Abbott before becoming law.

Judith McGeary, head of the Farm and Ranch Freedom Alliance, said her group is excited to see the measure advance and that it would broaden “options for the farmers and the consumers who are looking for healthy, locally-made foods.” Texas has been among the more restrictive states in allowing foods to be sold at markets, she said.

Texans have been able to hawk pickled cucumbers in local venues since 2013, when Rodriguez, an Austin Democrat, authored a law that let cooks sell certain goods without first becoming licensed food manufacturers. But an unexpected rule authored by the state’s Department of State Health Services has barred home chefs from selling any other kind of pickled produce without first installing a commercial kitchen, taking a course, and obtaining a special license.

“Only pickled cucumbers are allowed,” an FAQ section on the agency’s website specifies. “All other pickled vegetables are prohibited.”

The rule was drafted to implement the new law, and a department spokesperson told the Texas Tribune last May that the agency did not receive objections to the pickle definition. The spokesperson declined to comment Tuesday.

[…]

Laws authored by Kolkhorst and Rodriguez had already made it easier for home cooks to peddle their goods at local markets, by exempting them from regulations that some consider onerous. An old rule that small-batch bakers have a commercial kitchen, for example, was jettisoned in 2011. The exemption was extended to a host of other foods in 2013, including fruit butters, popcorn and pickles — though the State Health Services department took that to mean pickled cucumbers only.

As the story notes, a couple who intended to make some money pickling vegetables filed a lawsuit against State Health Services, which brought the issue to light. The story also notes the cottage food law, which passed in 2011 in its second attempt. I am as before on the side of the home foodies, so I’m glad to see this bill get passed. Hopefully, there will be no more weird bureaucratic interpretations necessitating further bills like this one.

What’s going on in Skull Creek?

Here’s a story from a couple of weeks ago that you may have missed. I know I missed it until it was pointed out to me.

For more than two months, the waters of Skull Creek have flowed black, its surface covered in an iridescent sheen. Yellowed fish skeletons line the pebbled banks of the Colorado River tributary, and a dizzying chemical odor hangs in the air.

The odor is so strong that Julie Schmidt says she can smell it inside her house.

She and her husband bought 10 acres along the creek in December with visions of an idyllic country upbringing for their children, ages 10 and 2. Now, she isn’t sure they should play outside.

“Last summer, you could go into the creek behind the house and it was crystal clear. You could play in it, you could fish,” said Schmidt, who moved from nearby Garwood and has lived in Colorado County her entire life. “Now you don’t want to touch it. You pick up a rock, turn it upside down, and it’s completely black.”

Locals and elected officials in this small southeast Texas community near the intersection of Interstate 10 and Texas 71 say the source of the problem is obvious: an oil and gas waste recycling facility near the creek that is owned by Columbus-based Inland Environmental and Remediation. Although Inland has denied wrongdoing, the Texas attorney general sued the company Friday — 10 weeks after citizens first began complaining — alleging the company illegally discharged industrial waste into the creek and stored that waste without a permit.

On Friday, a state district court in Travis County granted a temporary restraining order against the company and its president, David Polston, saying he must “cease and prevent all discharges of waste” from the site into state waters.

The state’s lawsuit seeks monetary damages of up to $1 million.

The Texas Railroad Commission ordered the facility to stop storing oil and gas waste in 2017 as a result of a bankruptcy court reorganization. (The permit was held by Boundary Ventures, a company at the same location that lists Polston as its president and director.)

Records obtained by The Texas Tribune show that the Texas Commission on Environmental Quality dispatched inspectors to the facility Feb. 10 — the same day that Colorado County Judge Ty Prause says he made a formal complaint — and hand delivered a letter two days later demanding that Polston take immediate action to halt the discharge of waste into the creek. The letter described conditions at the facility as an “imminent threat and substantial endangerment to human health and/or the environment.”

But Prause, the county’s chief executive, said the agency left him and other officials in the dark for weeks about the origins of the pungent substance and what guidance he should give to his constituents to protect themselves.

“It’s hard to imagine that the state agencies in charge of protecting our environment and natural resources in Texas would not act quicker to tell people that live on this creek whether there’s a threat to their health or their livestock,” said Prause, who oversees emergency response for the county.

I encourage you to read the rest. Most of the coverage of this story has come from the Colorado County Citizen, with reporting by my friend and former blogging colleague Vince Leibowitz, who was the one to alert me to all this. Their first story, about the appearance of the black water and dead fish, is here, datelined February 15. The litigation referred to in the Trib story is ongoing, and I hope it will help uncover the truth about what happened, and hold the parties responsible for it to account. As Leibowitz wrote in an editorial, the “alphabet soup” of state agencies that have authority here have not been doing a good job, with the exception for the most part of the Railroad Commission. I don’t know what it’s going to take to figure out and clean up a big toxic waste spill like this, but we sure need to get on it.

Measles, schmeasles

Eh, no biggie.

With U.S. measles cases this year reaching historic levels since being practically eradicated nearly 20 years ago, a host of bills targeting vaccination policies in Texas don’t appear to be gaining traction in the Legislature.

The U.S. Centers for Disease Control and Prevention has confirmed 704 cases of the measles in 22 states so far this year, the most of any year since 1994. Fifteen of those cases have been in Texas, the Texas Department of State Health Services said.

Considering the scope of the crisis, Rekha Lakshmanan, policy director for the Immunization Partnership, a group devoted to eradicating vaccine-preventable diseases, said lawmakers this session are missing an important opportunity to pass what she called “common-sense immunization laws,” among them bills aimed at increasing data transparency.

Notable among those measures are Senate Bill 329, filed by Sen. Kel Seliger, R-Amarillo, which would require the Department of State Health Services to publish the immunization opt-out rates for individual public schools. Currently, the health department is only required to post this information for districts as a whole and private schools. Another, House Bill 1966 by Rep. Gene Wu, D-Houston, would empower child care facilities to list their immunization opt-out rates for parents who are interested.

Vaccine advocates say making this data available would help parents choose the best place to send their children, particularly if the children have compromised immune systems and can’t be vaccinated.

“If you cannot vaccinate your child, then you need to place them in a child care facility with children who are vaccinated, I think, for the obvious reason that you know those children would not spread it to your child if there is a contagion that goes through the population,” Wu said of his legislation.

Opponents say the information does not reflect the overall health of a facility and could lead to kids being discriminated against for not being vaccinated, even though names would not be published.

Lawmakers heard testimony on both bills in committee hearings last week but did not vote on either. Next week is the deadline for the House to advance bills. The Senate has until May 22.

See here, here, and here for some background. This story was from the weekend, so please note that the House deadline for voting out bills is tonight at midnight. After that, it’s Senate bills or attaching amendments if your bill died in committee. The anti-vaxxers complaints do not move me. I see this as a matter of giving parents the information they need to make good choices. If that means that preschools and child care facilities are less inclined to take kids whose parents chose not to vaccinate them because it’s bad for their business, well, that should tell you something.

Also, too:

Amid a record-breaking national outbreak of measles, the number of Texans who exempt their children from vaccination for non-medical reasons took another big leap this past school year.

The number increased 14 percent in 2018-2019, continuing a 15-year-long trend that public health officials worry is leaving communities vulnerable to the resurgence of preventable diseases such as measles, which has been confirmed this year in 23 states, including Texas. The number of measles cases this year is the largest since 1994.

“Seeing non-medical exemptions increase again on a double-digit scale should create outrage for everyone,” Allison Winnike, president and CEO of the Houston-based Immunization Partnership, said in a statement. “It’s time for Texans to take action.”

Porfirio Villarreal, public information officer for the Houston health department, added that it’s “disappointing to see yet another rise in the number of parents opting out of life-saving vaccines, mostly due to the vast amount of misinformation on the internet and social media channels.”

The number of exemptions are still small, 64,176, but they represent a roughly 2,000 percent increase since 2003, when the state began allowing parents to decline immunization requirements for reasons of conscience. There were about 3,000 in 2003-2004, and a little under 57,000 in 2017-2018.

[…]

Texas is one of 17 states that allow waivers of school vaccine requirements based on parents’ conscience or personal beliefs. Only three states — California, Mississippi and West Virginia — don’t grant exemptions on religious grants. All 50 states allow exemptions for medical conditions, such as a compromised immune system.

Of course, tightening up the rules for exemptions is not on the table at all. The report that produced this data breaks it down by school district but – as we know – not by individual school. I don’t even know what else to say.

There’s only one solution to the anti-vax crisis

They have to be beaten at the ballot box. There’s no other way.

On the South steps of the Texas Capitol, state Rep. Briscoe Cain prayed that the children standing beside him would not be mocked for their parents’ decision not to vaccinate them.

“We ask that you strengthen these children … we ask that you shield them,” said Cain, R-Deer Park. “May government leaders never forget that parents know what is best for their children.”

On Thursday, more than 300 anti-vaccination advocates and their children rallied with Texans for Vaccine Choice to support bills filed by a handful of state lawmakers that would require doctors to provide families with both the “benefits and risks of immunization,” and make it easier to opt out.

“I walk these halls and I see … the fun they are poking at our children and our families, and it angers me,” said the group’s president, Jackie Schlegel, who said her daughter is disabled due to complications from a vaccine. “The time is now to stand up, to be here for your families, to be here for your children, the ones who do not have a voice.”

Statewide data shows a steady rise in children whose parents have claimed conscientious exemptions from vaccine requirements. In 2018, 76,665 individuals requested affidavits for the exemption, an 18.8-percent increase over 2017, and a 63.8-percent increase since 2014, according to the Texas Department of State Health Services.

As the movement grows, Texas has seen a series of outbreaks of infectious diseases that were thought to have been virtually eliminated in the U.S.

You can see what we’re up against. Measles are back, someone was walking around the Capitol with whooping cough, idiots are deliberately exposing their own children to chicken pox, it goes on and on. Reason, civic duty, compassion for the immunocompromised, nothing moves these people. The one thing we can do is throw the legislators who coddle them out of office. Diminish their power, and the rest takes care of itself. So, just as a reminder:

Jonathan Stickland, HD92, won in 2018 by a 49.8% to 47.4% margin, in a district where Beto O’Rourke got 48.3% of the vote.

Matt Krause, HD93, won in 2018 by a 53.9% to 46.1% margin, in a district where Beto O’Rourke got 48.2% of the vote.

Bill Zedler, HD96, won in 2018 by a 50.8% to 47.2% margin, in a district where Beto O’Rourke got 49.5% of the vote.

I wish I could make a case for Briscoe Cain’s vulnerability, but alas, he’s in one of the two most Republican districts in Harris County. Still, take those three out and you’ve really weakened the anti-vax core. You want to see fewer kids get easily preventable diseases in Texas? There’s your starting point.

The anti-vaxxers keep on coming

Eternal vigilance, and some more problematic legislators getting booted out of office, are required.

Among the new Texas proposals is an “informed consent” bill filed by state Representative Bill Zedler, an outspoken anti-vaccine member of the House Public Health Committee. Zedler drew national attention after he downplayed the resurgence of measles, which he had as a child, telling the Observer last month, “Today, with antibiotics and that kind of stuff, they’re not dying [of measles] in America.” (Hundreds of Americans died of measles each year before the disease was considered eradicated in 2000, thanks in large part to the development of a vaccine. Also, antibiotics don’t treat measles, which is a virus.)

[…]

bill filed by state Senator Bob Hall, R-Edgewood, would ban vaccines that haven’t met criteria that Hall — a retired business owner — has determined the U.S. Food and Drug Administration should be using for approval. The bill also requires the state health department to post online a “disclosure of any known injuries or diseases caused by the vaccine” and that the vaccine be “evaluated for [its] potential to: cause cancer, mutate genes, affect fertility or cause infertility, and cause autism spectrum disorder.”< The bill is “dangerous” and a “misunderstanding of how science and clinical trials work,” Lakshmanan said. Any link to autism, first proposed in a now-retracted study, has been repeatedly debunked. “The insinuation of this legislation is that vaccines are not well-tested and not safe, which is erroneous, incorrect and misleading,” she said. Hall did not respond to a request for comment.

Also of top concern for immunization advocates are proposals to make it even easier to opt out of vaccine requirements, even as “conscience” exemptions have skyrocketed in Texas from about 2,300 in 2003 to nearly 53,000 in 2017. A bill filed by House Freedom Caucus member Jonathan Stickland, R-Bedford, would allow nurses to sign off on exemption forms rather than just doctors. Another, from state Representative Tony Tinderholt, would prohibit doctors from refusing to see patients who aren’t vaccinated. And one from caucus member Matt Krause would make it easier to submit vaccine exemptions, and prevent the state health department from tracking them. Health experts say this would prevent the state from preparing for potential disease outbreaks, as well as make it impossible for families of very young or immunocompromised kids to know which communities have low vaccination rates.

See here for some background. You can find all these bills and more by going to the Texas Legislature Online page and doing a word/phrase search for “immunization”. It’s not always easy to tell with the language in these bills, but SB1813 by Sen. Jose Rodriguez, which appears to loosen requirements for pharmacists to administer vaccinations, looks good. I don’t see anything positive relating to the so-called “conscience clause” exemption, which is what allows parents to enroll unvaxxed kids in school because they don’t want to get them immunized. I don’t think we’re there yet for something like this. The best we can do this session is most likely going to be not letting anything bad get passed. Then we need to follow it up by beating as many of these anti-vax schmoes at the ballot box as we can. Make note of those names, these are the targets of interest.

It’s hard being pregnant in Harris County

We need to figure this out.

Life-threatening, pregnancy-related complications — the iceberg beneath the surface of the U.S. maternal health crisis — are on the rise in Harris County, according to a new report.

The report not only confirmed the Harris County rate is worse than that of the state and nation, it found that it increased more than 50 percent between 2008 and 2015. Texas’ rate of life-threatening, pregnancy-related complications went up 15 percent in the same time period.

“In subtle and unintentional ways, women’s health in Harris County has been subjugated to the health of babies so profoundly that the health of women of childbearing age is often not prioritized,” says the report, a project of the Houston Endowment.

Dr. Lisa Hollier, a Houston obstetrician-gynecologist and a co-chair of the task force that produced the report, said Harris County’s high rates “point to the need for greater intervention to promote safety around the time of delivery. Such complications are 50 times more common than pregnancy-related deaths, but don’t get near the amount of attention.”

Hollier and Dr. Cecilia Cazaban, the report’s principal investigator, said it is unclear why Harris County’s rate is increasing at such a high rate. They said that analysis is next on tap for the task force.

[…]

The new report focuses on severe maternal morbidity, the term for conditions that require such treatment as a respirator or blood transfusions or hysterectomy during delivery or in the immediate hours thereafter. It can lead to maternal death, but even when the patient survives, it can cause damage, such as kidney or heart failure, sometimes requiring lifelong treatment. It also is costly to the patient and health care system.

Harris County’s rate of severe maternal morbidity in 2015 was 2.4 percent, meaning there were 238 cases for every 10,000 deliveries. The 2015 rate was 1.97 in Texas and 1.46 in the United States.

See here for some background. The task force website is here, though I don’t think this report is on there. I hope there’s no need for me to say anything more than we really need to understand this problem so we can solve it.

Abbott waives fees for birth certificates for individuals from hurricane-affected counties

From Diane Trautman on Facebook, also sent to me in email:

Governor Greg Abbott has approved a request allowing the state to waive fees for mail-in or walk-in birth certificate issuance requests, and local registrars to waive fees for walk-in birth certificate issuance requests, for individuals from hurricane-affected counties. This is important for several reasons, one of which is that a birth certificate is a valid form of supporting documentation for voters without proper ID who need to sign an Affidavit of Reasonable Impediment.

A list of the affected counties is at the announcement. The language used is pretty legalistic, so unless you are familiar with “Section 418.016 of the code”, you may not realize from the announcement just what this means, so thanks to Diane Trautman for the interpretation. You probably know someone, or know someone who knows someone, who needs to know this, so please pass it on.

And then there’s the birth certificate issue

Just another problem that would be exacerbated by a bathroom bill.

In order to modify a birth certificate in Texas, the Department of State Health Services requires transgender individuals to present a certified court order stating the recorded sex on a birth certificate should be changed.

But a transgender person’s ability to obtain that court order is largely determined by where they live and their socioeconomic status, according to transgender individuals, advocates and lawyers who have worked with transgender Texans on the process.

Some county judges — even in more liberal urban areas — are less eager than others to grant the court order that’s required by the state, particularly when it comes to children. That forces some transgender individuals to travel to counties like Travis, Bexar or Dallas, where such court orders can be easier to obtain.

It can also be an expensive process. Court filings fees can reach $300 even before adding on attorneys fees or travel requirements. The process can be even more cost-prohibitive for transgender individuals because they must also obtain letters from both a doctor and a mental health provider certifying they are transgender and under their care to present to the court. For some, that also presents a geographic barrier because Texas faces a shortage of doctors and therapists “who do this kind of work,” said Claire Bow, an Austin-area attorney who helps transgender people obtain updated documents.

But for Bow, there’s a bigger flaw with Republicans’ proposals for bathroom restrictions and the expectation that transgender people could immediately take steps to obtain updated documents.

“The important thing to understand is it’s never the first step in the process,” Bow said of amending birth certificates or IDs. Bathroom bills assume that every transgender person has “gone all the way through the process” or have reached the point in treatment at which their doctors and therapists will sign off on the letter needed for court.

“That’s why this is hard,” she added. “Nobody wakes up one day…and changes their sex.”

The outcome of this complex process is that many transgender Texans live with birth certificates that don’t align with their gender identity for years if not their entire lives.

This is not the first time this issue has been brought up. Getting one’s birth certificate amended can be expensive and time-consuming, and if you happen to have been born in the wrong state, legally impossible. One way Republicans could address this issue would be to make it less cumbersome to amend a birth certificate, with some provision for the folks whose home states have no such mechanism. Of course, if they were inclined to do that, it might lead them to the conclusion that the bathroom bill is ridiculous and harmful and serves no purpose.

This session’s unconstitutional abortion bill passes

Here we go again.

Right there with them

Texas senators voted Friday to send a bill banning the most common second-trimester abortion procedure and changing how health care facilities handle fetal remains to Gov. Greg Abbott’s desk.

Under Senate Bill 8, which passed 22-9, health care facilities including hospitals and abortion clinics would be required to bury or cremate any fetal remains — whether from abortion, miscarriage or stillbirth. The bill would also ban facilities from donating aborted fetal tissue to medical researchers, and aims to outlaw “partial-birth abortions,” which are already illegal under federal law.

Most controversially, the bill now bans dilation and evacuation abortions — a common second-trimester procedure where doctors use surgical instruments to grasp and remove pieces of fetal tissue — unless the fetus is deceased. Medical professionals deem the current method the safest way to perform the procedure on a pregnant woman, and reproductive rights groups have said this change would subject women to an unnecessary medical procedure.

[…]

Amanda Allen, senior state legislative counsel for the Center for Reproductive Rights, said in a news release that Texas legislators are continuing “their crusade against a woman’s right to safe and legal abortion.”

“Texas women deserve access to the health care that is best for them and their personal circumstances — not abortion restrictions pushed by extreme anti-abortion organizations,” Allen said. “The Center for Reproductive Rights vows to battle any unconstitutional measures in the courts until the rights of Texas women are respected and protected.”

The group sued late last year over a Texas Department of State Health Services proposal requiring health providers to bury or cremate fetal remains. Center lawyers won a temporary restraining order and in January a federal judge ruled Texas could not proceed with the rule, citing its vagueness and potential to harm patients.

See here for the background. I don’t know what to say that I haven’t said already, but if I’m going to repeat myself anyway, I’ll say this again: Nothing will change until the people we elect change. We have a chance to do something about this next year. It’s up to us.

Making vaccination information public

I support this.

While most parents in Texas vaccinate their children, the number of parents opting out of immunizations for non-medical reasons is on the rise. Since Texas changed its laws to allow parents to opt out citing a conscientious objection, the number of unvaccinated children has shot up more than 1,700 percent in 13 years, to 45,000 from 2,300. In response, parents and health advocates are backing an effort to increase public reporting on how many students who have skipped vaccines attend each school.

Currently, that data is housed at the state level and available via an open-records request. County and school district-level data also is available online.

House Bill 2249 would require the Texas Department of State Health Services to publish school-by-school data that would indicate the total number of students who forgo vaccinations, including those who opt out by choice, such as a religious objection. No names or identifying information would be listed.

Advocates for publishing the data say the information would offer parents insight into their child’s school and help them weigh whether to switch, particularly for parents of medically fragile children like Riki Graves’ daughter, Juliana. Now 3, she received a new heart at 18 days old, and doctors say she will need to attend a school where least 95 percent of the students are immunized.

“My job as a transplant mom is to protect that organ,” said Graves as she drove from her home in Sugar Land to Austin where she plans to testify before the House Public Health Committee on Tuesday. “We have the data … there’s no reason not to publish it.”

Opponents say there are plenty of reasons, including children’s medical privacy.

“If this is truly about keeping children safe, we have to have that honest conversation about keeping all people safe. It puts a target on the backs of children whose parents have chosen to opt out for various different reasons,” said Jackie Schlegel, a mother of three and executive director of Texans for Vaccine Choice, a grass-roots parent group that has ballooned in recent years as the movement against vaccinating children has gained traction. The group is planning a rally at the Capitol on Thursday, dubbed the “freedom fight.”

“At schools where you do have a high number of opt-out, we are creating a witch hunt against families, and that’s just unacceptable,” Schlegel said.

We clearly have a different definition of “unacceptable”. I think knowing that a given school has a high rate of unvaccinated children is something any parent would want to know. HB 2249 has four co-authors, two of whom )JD Sheffield and John Zerwas) are medical doctors, which ought to tell you something. As the story notes, an identical bill passed the House in 2015 but never got a hearing in the Senate. Let’s hope this year’s version meets a better fate. The Trib has more.

House hears “fetal remains” bill

Seriously?

Rep. Byron Cook

[House Bill 35] would create a registry of organizations that can help pay for burial or cremation of fetal remains. That way, the cost associated with burials would not fall on women, [bill author Rep. Byron] Cook said.

The measure would not apply to miscarriages that happen at home.

“Let me be clear: this bill has nothing to do with abortion procedures whatsoever. It has everything to do with ensuring the dignity of the deceased,” Cook said Wednesday. “We believe Texas can do better than this.”

Cook said he’s opposed to a current method of disposal that allows for grinding up fetuses and disposing of them in sanitary landfills.

“What we’re doing is removing a very objectionable method of disposal. The good news is I haven’t talked to anyone who thinks grinding would be an acceptable method [of disposal],” Cook said. “We’re just really taking off the books something that should be objectionable to everybody.”

However, Cook was challenged during the hearing by state Rep. Jessica Farrar, D-Houston, who said the Republican should revise his bill to outlaw the disposal methods he doesn’t like without mandating burial.

“I think if you want to delete that language, you can delete that language without creating a burial requirement,” Farrar said. “I think we can find a way that is, in some people’s minds, more humane without creating burdens for women.”

[…]

Wednesday’s hearing comes weeks after U.S. District Court Judge Sam Sparks ruled Texas cannot require health providers to bury or cremate fetuses.

Sparks wrote in January that a fetal remains burial rule the Texas Department of State Health Services planned to implement was vague and had the potential for irreparable harm.

Yes, that would be the main sticking point, I presume. I also presume that it would be possible to write a bill to address this never-considered-a-problem-before-HB2-was-struck-down issue in a way that complies with Judge Sparks’ order. I’m not a lawyer, so I can’t say if this bill might do that, but I do know that the lawyers who represent the clinics that would be affected by this law, as they would have been affected by the State Health Services rule that Judge Sparks blocked, will be able to say. And to do, if it comes to that.

“Fetal remains” rule blocked

Good.

U.S. District Court Judge Sam Sparks ruled Texas cannot require health providers to bury or cremate fetuses, delivering another blow to state leaders in the reproductive rights debate.

On Friday afternoon, Sparks wrote in his ruling that Texas Department of State Health Services’ fetal remains burial rule’s vagueness, undue burden and potential for irreparable harm were factors in his decision. He also wrote that the state had proposed the new rule “before the ink on the Supreme Court’s opinion in Whole Woman’s Health was dry.”

“The lack of clarity in the Amendments inviting such interpretation allows DSHS to exercise arbitrary, and potentially discriminatory, enforcement on an issue connected to abortion and therefore sensitive and hotly contested,” Sparks said.

[…]

During two public hearings, department leaders heard stories of abortions, miscarriages, and general grief over losing a baby. While anti-abortion groups argued that the rule was a means to bring human dignity to the fetuses, reproductive rights advocates said the rule was another way for Texas to punish women who chose an abortion, saying the cost of the burials would be passed on to patients, making abortions harder to obtain for low-income Texans.

During multi-day court hearings earlier this month, state attorneys said the rule was designed to provide aborted or miscarried fetuses a better resting place than a landfill. They also argued that there would be no cost for patients to worry about and only miniscule costs for providers. The state also said that there were multiple groups willing to help with costs.

But Center for Reproductive Rights lawyers argued the rule had no public health merits and no clear directions on how it would work for providers. Providers who testified noted it was unclear if they would be on the hook for fines and disciplinary action from Texas if the nonprofit groups mishandled the fetuses. They also said separating fetuses away from other medical waste would likely mean an uptick in costs for transportation and new disposal procedures.

Sparks expressed frustration throughout the court proceedings that neither side could provide a firm estimate of the costs of implementing the rule. He also, one point, agreed with Center for Reproductive Rights attorneys’ argument that there would be no public health benefits.

In his ruling, Sparks wrote that the department’s estimates don’t know “the true impact” of the rule and that their “simple math” is “unsupported by research and relies heavily on assumptions.”

See here, here, and here for the background, and here for a copy of the order; the full order is here. Note that this is just an injunction pending the actual lawsuit to overturn the ruling. The injunction strongly suggests that Judge Sparks thinks the plaintiffs will prevail, but that matter has not been decided yet. Now a trial date will be set and we will proceed from there, while the state will pursue an appeal to rescind the injunction and allow the rule, which had been scheduled to take effect on Friday, to be put in place for the duration of the trial.

Republicans like Ken Paxton are predictably gnashing their teeth about this, but if this rule was so important for the sanctity of life and dignity of the mothers and whatever else, then why wasn’t it proposed earlier than last year in the immediate wake of the HB2 ruling? Rick Perry could have proposed this a decade or more ago. Greg Abbott could have proposed it in 2015. If it was so damn important, why did they wait so long? Who had even heard of such a thing before last year? The timing of the rule gives the show away. It deserves the fate it got from Judge Sparks. A press release from the Center for Reproductive Rights is here, and the Chron, the Statesman, the Current, and the Austin Chronicle have more.

SB6 will hurt people

It will hurt transgender people, who despite what Dan Patrick would have you think, are people like you and me.

Lieutenant Governor Dan Patrick has said his so-called bathroom bill isn’t discriminatory because transgender people can update their birth certificates to reflect their gender identity.

However, statistics obtained by the Observer from the Department of State Health Services (DSHS) suggest that fewer than 1 percent of transgender Texans have updated their birth certificates, meaning the overwhelming majority could be forced to use restrooms that don’t match their gender identity under Senate Bill 6.

LGBT advocates said the DSHS statistics, which have not before been made public, underscore the obstacles transgender Texans face if they seek to correct their gender markers on state identification documents.

[…]

According to DSHS, a total of 497 Texas natives updated their birth certificates “to reflect a medical or surgical sex change” from 2006 to 2016. Last year, the Williams Institute at UCLA estimated that 125,000 transgender adults reside in Texas.

DSHS spokesperson Chris Van Deusen said the department doesn’t specifically track the number of transgender people who’ve corrected their birth certificates. However, in response to a request from the Observer, the state agency compiled the data based on how many people have updated their birth certificates using a court order.

“A court order is required to change the sex due to a medical or surgical sex change but not for a change due to an error,” Van Deusen said. “We’re reasonably confident this captures all changes to sex on birth certificates due to a court order.”

Texas has no standardized procedure for transgender people to update their birth certificates or driver’s licenses, and judges in only three of the state’s 254 counties — Bexar, Dallas and Travis — routinely issue court orders granting gender-marker changes, according to LGBT advocates. Last year, a Texas appeals court in Harris County rejected a trans man’s petition for a gender-marker change on his driver’s license.

There’s no standard procedure for updating one’s birth records. If you were born in another state, which may or may not even allow for this kind of correction, you may be out of luck. If you’re under 18, you are definitely out of luck. Even if all of these procedural issues could be resolved, this would still be discriminatory. Why should trans people have to go through all of this time and expense to be able to use a public restroom?

By the way, this is somewhat parallel to the experience of gays and lesbians before the Obergefell decision, in that in order to mimic the legal rights and protections granted under the law to straight married couples, they had to jump through dozens of legal hoops, often spending hundreds or thousands of dollars in lawyers’ fees to achieve it. Requiring a class of people to expend time and money on things that everyone else gets to have for free no questions asked is the definition of discrimination.

Trans people have been using bathrooms without any fuss for decades. It was never a problem until Dan Patrick decided it was one. His “remedy” to this non-problem will help no one, but it will hurt many people. There are lots of valid business and economic reasons to oppose SB6, and I thank the people in the business community who have helped lead the fight against it. But at the end of the day, this is about treating people as people. Dan Patrick wants to treat some people as something less. I cannot abide that.

“Fetal remains” rule still on hold

Take all the time you need.

As he considers a final ruling on the state’s fetal remains burial rule, U.S. District Court Judge Sam Sparks is delaying the start date of the rule for at least another three weeks.

On Wednesday afternoon, after attorneys for the state of Texas and the Center for Reproductive Rights made their closing remarks, Sparks said he would need more time to review evidence and witness testimony before making a final ruling about the state’s effort to require medical providers to bury or cremate aborted fetuses. The Texas Department of State Health Services had originally scheduled the rule to go into effect Dec. 19.

[…]

For the state, Sparks said he wanted further explanation on the logic behind barring providers from incinerating fetal remains, a medical waste procedure the state has long allowed. He also wanted direction on why the state’s rule should not be viewed as a political statement. He said he did not “think there’s any question” that there isn’t public health benefit to the proposed rule.

“There’s no health benefit, there’s no health problem, there was no problem to be fixed and it’s for the dignity of the fetus or however you want to describe it,” Sparks told state’s attorneys. “I think all life matters and needs dignity but that’s not the point…the point is just as I asked opposing counsel: ‘what is the thought of taking the majority of disposal out?'”

Sparks told attorneys with the Center for Reproductive Rights that he wanted them to identify from their evidence and witness testimony how the rule is unconstitutional and how it would create a burden for women.

Sparks said neither side had made headway on establishing how provider’s costs would be impacted if the rule were implemented.

See here and here for the background. This was a two-day hearing – here’s the Trib story from Day One.

Attorneys for the Center for Reproductive Rights, which sued to stop the rule, called witnesses at Tuesday’s hearing who continuously expressed that the rule is “vague,” doesn’t give enough clarity for medical providers and has no public health benefits.

Amy Hagstrom Miller, founder and CEO of Whole Woman’s Health, the main plaintiff in the case, said on the stand that the rule was “discriminatory” and “offensive.” She said while groups like the Texas Conference of Catholic Bishops have stepped up to take on the cost of cremations and burials, the rule is unclear about who would be responsible for making sure the remains are properly disposed of. She said that vagueness puts providers in a vulnerable position where they could face fines or disciplinary actions by the state if those non-medical groups do something wrong. Also troubling, Miller said, is that it’s difficult for abortion providers to keep a steady roster of medical waste vendors due to alleged harassment from anti-abortion groups.

“It’s confusing for most of us to figure what a clear path would be to compliance,” Miller said. “I find words like ‘interment’ and ‘incineration’ and ‘cremation’ and ‘funeral’ are really confused and used intermittently in a way that is difficult for us to understand and difficult for the public to understand.”

The Statesman notes that the Ag had a bit of a rough time on Tuesday.

U.S. District Judge Sam Sparks abruptly halted a hearing on the constitutionality of the rule and ordered state lawyers to appear in his Austin courtroom, with answers, at 8:30 a.m. Wednesday — a half-hour before the hearing was set to continue for a second and final day.

Visibly frustrated, Sparks said it appeared that the rule, drafted by state health officials and praised by Republican leaders for prohibiting fetal remains from being deposited in sanitary landfills, appeared to improperly countermand a state law allowing cremated ashes to be scattered over any private property with the owner’s consent.

“I want the state to give me answers about how one regulation can overrule another state statute,” the judge said.

[…]

The lead lawyer for the state, John Langley with the attorney general’s office, challenged both abortion providers by repeatedly pointing out that “the rules don’t regulate women at all,” but instead require health care centers to ensure that fetal tissue is properly buried or cremated. Nor does the rule impose funeral requirements on women because it doesn’t require individual burials for each fetus, he said.

Langley also argued that concerns about increased costs were overblown, pointing out that the abortion providers’ own economist estimated that the new rule would add only 54 cents to $1.56 in costs per abortion.

However, economist Anne Layne-Farrar testified that the anticipated cost was based on an estimate provided by the only crematorium that appeared willing and able to handle fetal tissue at a feasible cost. The Dallas-area crematorium, however, is unlikely to be able to handle medical waste from all Texas abortion facilities, let alone from doctor’s offices that provide miscarriage care, she said.

Layne-Farrar also said it was risky to rely on one vendor that, if lost, would force abortion providers to turn to funeral homes that would likely charge $500 to $700 per cremation.

When a lawyer for Texas suggested that clinics could save money by cremating several weeks’ worth of fetal tissue at a time, Layne-Farrar said most of the 11 funeral homes contacted for her study said ethical considerations prohibited them from cremating or burying more than one body at a time.

Does any of that give you confidence that this was something other than a hastily-decreed retaliation for the SCOTUS HB2 ruling from last year? I mean, come on. Judge Sparks had previously been expected to rule on Friday, but clearly we’re going to have to wait a little longer than that. The Chron and the Austin Chronicle have more.

The religious objection to the “fetal remains” rule

It may not be your religion, but who are we to tell people of sincere religious faith what to do?

“The Satanic Temple believes burial rites are a well-established component of religious practice. In addition, members of The Satanic Temple believe in the inviolability of the body and, as such, these rules contradict our fundamental beliefs,” reads a statement posted on the Satanic Temple’s website.

Temple spokesman Lucien Greaves said that health officials’ transparent attempt to give fetal tissue the same rights as a human being (called “personhood” by anti-abortion advocates) directly conflicts with the temple’s beliefs.

“It’s clear these officials deem harassment an acceptable form of pushing their misguided religious agendas,” he said in a [recent] press release.

Citing the Religious Freedom Reform Act, Greaves said members are immune from the new regulation unless the state can present a “compelling reason” for why they should be allowed to violate the Temple’s religious beliefs. So far, church members don’t see one.

“Clearly, the State of Texas has no compelling reason because these rules were not enacted to promote health and safety, but rather to harass and burden women who terminate their pregnancies,” the Temple’s website states, adding that the church will use the legal system to protect their members’ rights.

It’s not an empty threat. “We’ll file an injunction as soon as the state tried to impose this on a member who claims exemption,” the Temple spokesman Greaves told Jezebel.

All righty then. This was from a little while ago, I just hadn’t gotten around to posting it yet. As the story notes, the Satanic Temple has previously sued the state of Missouri over religious objections to that state’s 72-hour waiting period for an abortion. As we know, the “fetal remains” rule is now on hold thanks to the Center for Reproductive Rights, but that doesn’t mean the Temple can’t file its own lawsuit. If nothing else, you have to admire their willingness to throw the language of “religious freedom” back in the state’s face. If you’re going to insist that laws should not apply to religious organizations if those laws conflict with their faith, then you have to accept that this also applies to faiths you don’t care for. The Austin Chronicle and the Press have more.

“Fetal remains” rule put on hold

Good.

A federal judge has delayed Texas’ fetal remains burial rule until Jan. 6.

Judge Sam Sparks ruled Thursday afternoon that the Texas Department of State Health Services would have to push back its start date for requiring health providers to bury or cremate aborted fetuses. The agency had originally slated the rule to go into effect Dec. 19.

Under the rule, Texas health providers are forbidden from disposing of fetal remains in sanitary landfills, regardless of gestation period.

Sparks said each side would get about five hours for a hearing on Jan. 3-4 to make their cases. He said there would likely be a decision on Jan. 6.

See here for the background. The state argued that there is “no increase in costs to health care providers and patients”, which is only true if the funeral homes that had been disposing of remains pro bono in the past do not pass along the significant costs that this rule imposes on them.

The Austin Chronicle adds some details.

Sparks appeared far more confrontational toward state defendants, commenting that Texas must show reasons for implementing the rule other than “political” ones. He also cast ample skepticism on the state’s timing of the rule – filed just four days after their loss in the House Bill 2 case at the U.S. Supreme Court – calling it “curious,” more than once. In a moment of commentary, Sparks said the war against abortion rights is raging “quicker and meaner” than it has in the last 40 years.

State assistant attorney John Langley defended the rule as a “modest step” to protect the unborn, but failed to give evidence of its public health benefit. He argued that the rule in “no way regulates a woman’s right to choose” or places an imposition on clinics. Revealing the intention of the anti-choice regulation, Langley was unable to answer how the rule practically advances a health and safety interest – the very objectives the state health department is tasked with. When asked about how the rule prevents the spread of disease and protects health, the attorney called it a “side issue” to the real goal: Protecting the “dignity” of the unborn. “I acknowledge I don’t have a satisfactory answer, your honor,” said Langley.

Following the hearing, CRR’s Brown called the state’s inability to provide a health rationale “remarkable” and more evidence that the rule is meant to “disrespect” abortion-seeking women. “This rule is really intended to send a message to the Supreme Court that Texas is defying them,” said Brown.

When Langley objected to the temporary restraining order, an agitated Sparks noted that “this is the first time the state of Texas has ever said it was going to go ahead [with a rule] when there’s a suit of substance before the federal court,” and before full trial arguments were heard. “I’m going to remember that.”

Perhaps a contempt charge might be in order, if it comes to that. I mean, look, if this rule is so necessary, then why did it take the state so long to implement it? It didn’t require legislative intervention, just a word from the Governor to State Health Services. Rick Perry could have done this. Greg Abbott could have done it in 2015. Heck, Dubya could have done it. Why did it not happen until shortly after the Whole Women’s Health ruling? The question answers itself. Trail Blazers, the Current, the Press, and the Chron have more.

“Fetal remains” lawsuit filed

As expected.

Today the Center for Reproductive Rights filed new litigation against the state of Texas over unconstitutional new regulations that mandate the burial or cremation of embryonic and fetal tissue that results from abortions, miscarriages, or ectopic pregnancy surgery – regardless of the woman’s personal wishes or beliefs.

The politically-motivated rules are designed to restrict a woman’s right to access safe and legal abortion by increasing both the cost of reproductive health care services and the shame and stigma surrounding abortion and pregnancy loss.

The lawsuit demands that the state halt implementation of regulations finalized late last month by the Texas Department of State Health Services (DSHS). The final rules disregard widespread objection from medical organizations, legal experts and others who argue that these unconstitutional new restrictions offer no public health or safety benefit.

The regulations – first proposed just four days after the U.S. Supreme Court’s historic Whole Woman’s Health v. Hellerstedt decision in June – are in direct defiance of the high court’s ruling, which held that restrictions on legal abortion cannot impose burdens on a woman’s right to access abortion care without providing any legitimate, medical benefit.

Said Nancy Northup, President and CEO of the Center for Reproductive Rights:

“These regulations are an insult to Texas women, the rule of law and the U.S. Supreme Court, which declared less than six months ago that medically unnecessary restrictions on abortion access are unconstitutional.

“These insidious regulations are a new low in Texas’ long history of denying women the respect that they deserve to make their own decision about their lives and their healthcare.  

“The Center for Reproductive Rights will continue to fight for Texas women, and women across the nation, to ensure their rights are protected.”

Said Amy Hagstrom-Miller, president and CEO of Whole Woman’s Health, lead plaintiff in the case:

“Texas’ profound disrespect of women’s health and dignity apparently has no bounds with this new regulation announced just days after our June victory in the Supreme Court. This latest attack is an end run game to add restrictions on abortion care and it ignores thousands of Texan’s testimony and comments.

“We at Whole Woman’s Health have a history of fighting restrictions that are deeply rooted in shaming and stigmatizing Texans and today’s filing is no different. We will not stand for Texas putting more undue burdens on women and families who deserve the safe and compassionate abortion care that we provide at Whole Woman’s Health.”

Today’s lawsuit was filed by David Brown and Molly Duane of the Center for Reproductive Rights, Austin attorneys Jan Soifer and Patrick O’Connell of the law firm O’Connell & Soifer, and J. Alexander Lawrence of the law firm Morrison & Foerster in the U.S. District Court for the Western District of Texas on behalf of Whole Woman’s Health, Brookside Women’s Health Center and Austin Women’s Health Center, Alamo Women’s Reproductive Services, Reproductive Services and Dr. Lendol Davis.

The regulations are part of an ongoing attack across the country to restrict access to legal abortion through unnecessary regulations that endanger women’s health and safety. State legislators have passed more than 330 new restrictions on abortion access in the last five years alone.

The new litigation comes as Texas faces a $4.5 million legal bill over its defense of the sham clinic shutdown laws struck down by the Supreme Court in Whole Woman’s Health v. Hellerstedt.

See here and here for the background. As I said before, I expect the plaintiffs will be able to get an injunction at the district court level, but after that anything can happen. I will of course be keeping an eye on it. The Trib, the Austin Chronicle, the Current, the Chron, and Trail Blazers have more.

“Fetal remains” lawsuit in the works

Get ready.

Health providers and abortion clinics have less than two weeks to figure out how to comply with Texas’ new fetal remains rules — that is, if a lawsuit doesn’t halt the process first.

Amy Hagstrom Miller, founder of abortion provider Whole Woman’s Health, said she is working with the Center for Reproductive Rights on a potential lawsuit opposing the rules. Any lawsuit would need to be filed next week because the rules are set to take effect Dec. 19.

“Here we are, with a situation where Texas is trying to restrict access to safe abortion care by any means necessary,” she said. “It’s really cruel.”

[…]

Health care entities haven’t said how they will comply. Hagstrom Miller, one of the plaintiffs in the Supreme Court abortion case, said that she is still working on a path to compliance but that Whole Woman’s Health is first trying to determine what the rules would entail.

“The regulations as written are very confusing,” she said. “We’re trying to figure out exactly what the law requires.”

See here for the background. I feel reasonably confident that an injunction can be had in district court. What happens after that, with the Fifth Circuit and SCOTUS, is anyone’s guess. But the Center for Reproductive Rights (who you should totally support) won before, and I have faith they can win again. It’s just a damn shame they have to.

The costs of the “fetal remains” rule

This is going to cost a lot of people a lot of money.

State health officials have contended that the “minimum costs in complying with the rules” would total $450 a year per health care facility, arguing that those costs would be offset by the elimination of the cost of landfill disposition.

But Michael Land, a funeral home director and spokesman for the [Texas Funeral Directors Association], said that’s unrealistic and that the costs associated with compliance are likely a “higher dollar amount than what they’re projecting.”

Cremations through a third-party crematorium range from $75 to $100 per specimen. If individuals choose burials, the minimum cost of a small space in a cemetery is $500 and caskets of the appropriate size would likely cost $100, Land said.

If you add labor on the part of the funeral home, the fees could go into the thousands of dollars, he added.

Responding to those concerns, a spokeswoman for the Texas Health and Human Services Commission said the rules don’t require that “these processes” go through funeral homes. Health care providers can work directly with crematoriums or medical waste companies to comply with the rules, said spokeswoman Carrie Williams.

“[Funeral homes] don’t have a mandatory role, and funerals are not required by these rules,” Williams said. “Incineration is still available as an option.”

But the rules indicate that incineration of fetal remains must be followed by interment. State health officials define interment as the “disposition of pathological waste using the process of cremation, entombment, burial, or placement in a niche or by using the process of cremation followed by placement of the ashes in a niche, grave, or scattering of ashes as authorized by law.”

Among the few exceptions to the rule are miscarriages or abortions that occur at home. But fetal remains from miscarriages that occur at health care facilities will still require interment — even if the patient does not desire it.

For those in the funeral business, the increased demand for cremations could mean ending their practice of charitably cremating the tissue from a miscarriage for parents who wished to have a funeral.

“What had always been pretty much a charitable process is now going to become costing quite a bit of money,” Land said. It’s estimated that 10 to 20 percent of pregnancies end in miscarriage.

See here for the background. Someone is going to pay for this little unfunded mandate, and there are a lot more women who have miscarriages than abortions. Remember, this only became a thing after HB2 was thrown out by SCOTUS last year. With any luck, this will meet a similar fate after it takes effect on the 19th.

“Fetal remains” rule goes into effect

Cue up that next lawsuit.

Texas’ proposed rules requiring the cremation or burial of fetal remains will take effect Dec. 19, according to state health officials.

Despite intense outcry from the medical community and reproductive rights advocates, the state will prohibit hospitals, abortion clinics and other health care facilities from disposing of fetal remains in sanitary landfills, instead allowing only cremation or interment of all remains — regardless of the period of gestation.

[…]

Proposed at the direction of Republican Gov. Greg Abbott, the health commission had argued the rules would result in “enhanced protection of the health and safety of the public.” Abbott said in a fundraising email that the rules were proposed because he doesn’t believe fetal remains should be “treated like medical waste and disposed of in landfills.”

But the new requirement prompted outrage from the reproductive rights community, which accused state leaders of pushing unnecessary regulations. Women who experienced miscarriages or lost children in utero questioned why the state would make their situations more difficult by enacting the requirements. And medical providers — including the Texas Medical Association and the Texas Hospital Association — had also raised concerns about who would bear the costs associated with cremation or burial — a figure that can reach several thousand dollars in each case.

In response to those concerns, health officials indicated that health care facilities — and not patients — will be responsible for the disposal of fetal remains and related costs. They also wrote that those costs would be “offset by the elimination of some current methods of disposition.”

See here, here, and here for the background. If you think it’s a coincidence that this was proposed within a few weeks of the SCOTUS ruling striking down HB2, I’ve got a carload of diplomas from Trump University to sell you. Let’s get that next lawsuit going so we can maybe have an injunction in place before this atrocity can take effect. (And if you want to help facilitate that, a donation to the Center for Reproductive Rights would be a fine way to do so.) The Austin Chronicle has more.

We’re going to be fighting about vaccinations for a while

I wish it weren’t so, but it is.

Texas is one of 18 states that allow non-medical exemptions to the vaccines required for school attendance. California had a similar law allowing non-medical exemptions, until last year when it enacted a law that has one of the strictest requirements in the country after a 2014 outbreak of measles traced to the Disneyland theme park infected more than 100 people around the country.

Many of the parents opting out of the immunizations, which are widely recommended by doctors, say they fear a link between the vaccines and health problems such as autism. But studies that they cite have been widely debunked by public health officials.

“Year after year we’ve seen a steady increase in the number of students with a conscientious exemption from vaccination in Texas,” said Christine Mann, a spokeswoman for the Texas Department of State Health Services. “But overall, the numbers are small.”

Even though statewide levels of vaccinations remain high, at over 98 percent, what concerns public health officials are the growing clusters of geographic areas with high rates of unvaccinated children. Texas went from just 2,314 “conscientious exemptions” in 2003 to 44,716 this year, according to the Texas Department of State Health Services.

Some parents are pressing state officials to let them know how many of their children’s peers are unvaccinated. Jinny Suh, who has a 4-year-old son, is helping spearhead a petition drive asking legislators to change state law so that the number of school exemptions is public. Currently, exemption rates are available for individual private and charter schools, but only district-wide for public schools.

State Rep. César Blanco, a Democrat from El Paso, introduced a bill during the last legislative session that would have required schools to notify parents about vaccination rates at the school level, but the bill was stalled in committee.

“As a parent, there are lots of things that people get very passionate about,” Suh said, “but for some reason, in my experience, vaccinations remains an almost taboo topic besides a few passionate people.”

Yes, the anti-vaxxers are a minority, but they are a vocal and organized minority, which is a recipe for political success. Unfortunately, the end result of that political success is a growing public health problem, which is compounded by a lack of leadership in our state government. Honestly, what we need here is for an organized pushback against the anti-vaxxers, a pro-vaccine Moms Demand Action kind of thing. The main difference here isn’t that there is an anti-vaccination legislative faction that needs to be countered. I doubt there are that many legislators who are truly anti-vaccination, though there are a decent number who are in favor of “conscience” objections to some extent. It’s more that there isn’t a vocal and active pro-vaccination legislative force that can advance the cause and/or defend against attempts to weaken vaccination requirements. People who want to see more kids get vaccinated and fewer kids get exempted from vaccinations need to elect a few of their own. Until that happens, we’re going to see more stories like this one.

The next abortion lawsuit should be on its way

We were warned it would need to happen.

Despite intense outcry from the medical community, reproductive rights advocates and funeral directors, Texas isn’t budging on a proposed rule to require the cremation or burial of fetal remains.

Following an initial public comment period that sparked medical concerns and a legal threat, Texas health officials have re-submitted for public consideration a proposed rule change that prohibits hospitals, abortion clinics and other health care facilities from disposing of fetal remains in sanitary landfills, instead allowing only cremation or interment of all remains regardless of the period of gestation — even in instances of miscarriages.

After considering hours of public testimony at an August hearing and more than 12,000 comments submitted in writing, the state made no changes to the rules, which are set to be published in the Texas Register on Sept. 30.

The rules were re-published “after reviewing the feedback and comments we received,” health commission spokeswoman Carrie Williams said on Wednesday. This will require another 30-day public comment period before the rules can go into effect.

[…]

The proposed rule has prompted outrage from the reproductive rights community, which has accused state leaders of enacting unnecessary regulations. Medical providers — including the Texas Medical Association and the Texas Hospital Association — also questioned why the rule change does not allow an exception for miscarriages and ectopic pregnancies.

Despite making no revisions to the rules themselves, the commission has amended its analysis on the financial impact of the rule on health care organizations that must comply, saying the rules won’t increase “total costs” for health care facilities.

Medical professionals and funeral directors had raised concerns about who would bear the costs associated with cremation or burial — a figure that can reach several thousands dollars in each case — and questioned whether the new would trigger a requirement for death certificates so that fetal remains could be cremated or buried. (Under current rules, the state requires funeral directors or a “person acting as such” who take custody of a dead body or fetus to obtain an electronic report of death before transporting the body, according to the Funeral Consumers Alliance of Texas.)

The amended fiscal analysis indicates that the methods allowed in the proposed rules “may have a cost” but “that cost is expected to be offset” by costs currently incurred by facilities. Hospitals and abortion providers currently contract with third-party medical waste disposal services.

See here and here for the background. All this happened by executive order, with no legislative input or public hearings, in the immediate aftermath of the SCOTUS decision striking down the odious HB2. If the words “undue burden” have not formed in your head by now, you need to go back and read that decision again. I guarantee, once this rule is in place, a lawsuit will follow.