The man was a grocery store clerk — an essential worker — and the sole earner for his family. A 14-day isolation period would put him at risk of getting fired or not having enough money to make rent that month. But he had just developed classic COVID-19 symptoms, and many others around him in Chelsea, Massachusetts, had confirmed cases. Even with the negative test, his chances of having the disease were too high to dismiss.

For many Americans, including clinicians like Chu, who specializes in primary care and infectious disease at Massachusetts General Hospital, the pandemic has forced difficult conversations about the limits of medical tests. It has also revealed the catastrophic harms of failing to recognize those limits.

“People think a positive test equals disease and a negative test equals not disease,” said Dr. , who heads the general medicine division at Memorial Sloan Kettering Cancer Center in New York City. “We’ve seen the damage of that in so many ways with COVID.”

National COVID test shortages have emphasized testing’s critical role in containing and mitigating the pandemic, but these inconvenient truths remain: A test result is rarely a definitive answer, but instead a single clue at one point in time, to be appraised alongside other clues like symptoms and exposure to those with confirmed cases. The result itself may be falsely positive or negative, or may show an abnormality that doesn’t matter. And even an accurate, meaningful test result is useless (or worse) unless it’s acted on appropriately.

These lessons are not unique to COVID-19.

Last year, David Albanese logged in to the online patient portal for his primary care doctor’s office and discovered that his routine screening test for the hepatitis C virus showed a positive result.

“I never considered myself somebody who’s in a high-risk category,” said the 34-year-old Boston-area college administrator and adjunct history professor. “But I just know that for a couple of days, I was really, really anxious about this test. I didn’t know if I should be behaving differently based on it.”

Within days, a confirmatory test showed Albanese did not actually have the potentially severe yet curable liver infection. Still, the memory of that false positive result gave him a new perspective on testing writ large. He had been skeptical of recommendations shifting breast cancer screening to older ages to reduce the psychological toll of false positives, but he said they made more sense after his own testing drama.

“‘Isn’t it better to do the screening regardless?’” he said he used to think. “Now I realize it is a little more complicated.”

These false positives are especially common for screening tests like hepatitis C antibody tests and mammograms that look for medical problems in healthy people without symptoms. They are designed to cast a wide net that catches more people with the disease, known as the test’s sensitivity, but also risks catching some without it, which lowers what is known as the test’s specificity.

Though some degree of uncertainty is inherent in all medical decisions, clinicians often fail to share this with patients because it’s complicated to explain and unsettling and leaves doctors vulnerable to seeming uninformed, said Korenstein. What’s more, doctors are trained to seek definitive answers and can themselves struggle to think in probabilities.

“High-tech diagnostic testing has led to this mirage of certainty,” said Korenstein. “Back in the day before there were MRIs and what not, I think, doctors were more cognizant of how often they were uncertain.”

Enter COVID. Coupled with genuine uncertainty about an emerging disease and a political environment that has sown misinformation and rendered science partisan, the nuances of testing are too often lost at a time when they are particularly crucial to convey.

Dr. , who specializes in infectious disease at the University of Nebraska Medical Center, was concerned to see Nebraskans tested at statewide facilities get “inconsistent results without a lot of guidance or explanation about what these results might mean.” When she offers COVID testing, she said, she approaches it as she does any other medical decision, starting with a simple question: “What do you want to learn from this test?”

To answer this, it helps to know something about how coronavirus tests work and how well they do their jobs.

Many of the available tests are meant to tell you if you’re infected right now. For example, polymerase chain reaction tests like the one Chu’s patient received detect small traces of genetic material from the virus. But by some estimates, those tests have a false negative rate of up to 30%, meaning . This rate also varies based on who collects the sample, from which part of the body and when in the course of a possible infection.

Antigen tests look for viral proteins and are faster to analyze than the PCR, but also less accurate.

To know if you’ve already had COVID-19, the closest you can get is the COVID antibody test. But the too-common interpretation is black and white: I had COVID, or I didn’t. Here, again, the reality is more nuanced. The test checks your blood for antibodies — your immune system’s soldiers in the fight against the coronavirus. A negative antibody test could mean you were never infected with SARS-CoV-2, or it could mean that you’re currently infected but haven’t yet built up that army, or that these defenses have already faded away.

A positive test, on the other hand, may have mistakenly detected antibodies to another, similar-looking virus. And even if the test correctly shows you had COVID-19, it’s not yet clear if this means you’re protected from reinfection.

Yet, these shades of gray are difficult to internalize. Roy Avellaneda, the 49-year-old president of the Chelsea City Council, got the antibody test out of curiosity and could not help but see his positive result as what he called an immunity pass. “I can act a little bit cavalier with it now,” he said. “Yes, I’ll continue to wear a mask and so forth, but the fear is gone.”

Korenstein said that’s a common though worrisome reaction. “It’s really hard to expect the public to have a more nuanced understanding when even doctors don’t,” she said.

Some of the uncertainty around COVID testing has abated as researchers learn more about the new disease. Early in the pandemic, health care providers retested patients with confirmed cases, looking for a negative PCR test to prove they were no longer infectious. But soon, epidemiologists discovered that a COVID patient rarely infected others 10 or more days after first developing symptoms (or 20, in severe cases), even if the PCR test was picking up traces of the — presumably dead — virus weeks or even months after initial infection. So the Centers for Disease Control and Prevention and health systems adjusted their policies to clear patients on the basis of time rather than a negative test.

But while the desire for certainty in coronavirus testing is magnified by the rampant uncertainty in other facets of pandemic life, this is simply not something most medical tests can provide.

This <a target="_blank" href="/public-health/how-covid-19-highlights-the-uncertainty-of-medical-testing/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

This is part of an occasional series, First Person.

Ganguli (Katherine Lambert)

The clinic starts at 5 p.m. sharp with a team huddle in the conference room. A black plastic tray of stale bagel halves and crusted cantaloupe sits on the table, remnants of a breakfast meeting, but despite our medical-student hunger, we focus on the task at hand.

At 5:15, patients start to arrive. Their paths have been carefully choreographed from waiting room to exam table, lab to social services. Our schedules, through vigorous debate, have been set to five-minute time slots and annotated in flow charts. The first- and second-year medical students take blood pressures and interview the patients. The senior students finish the exam and present each patient’s case — from poison ivy to possible kidney failure — to the supervising doctor, using practice guidelines printed in our thick orientation packets.

Other students fill in as patient coordinators, social workers, and lab directors, while the research and quality assurance team tracks data on patients’ health needs and wait times. The M.D./MBA candidates in the group designed the clinic’s business model with the goal of self-sustainability, but for now, we simply do our best to take care of our patients.

Each Tuesday evening, the internal medicine practice at lends its facilities to Harvard Medical School’s new student-faculty Ìý— the Crimson Care Collaborative (CCC). Medical schools across the country have similar student-run clinics, some decades old. More than a chance to play doctor, the clinic is a hands-on lesson in practicing primary care, the sort that forms the cornerstone of the “accountable care organizations” or “patient-centered medical homes” encouraged by the federal health overhaul law.

This evolving conception of primary care requires doctors and other primary health care providers to work in teams and to be creative about how they deliver care. Lawmakers have come to realize that it is critical for both improving our nation’s health and saving our wallets. Now medical training needs to change in kind.

My initial regard for primary care when I entered Harvard Medical SchoolÌýhas been distorted by frustrations I hear from practicing doctors and the not-so-subtle lure of a “lifestyle career” alternative, my putative reward for being smart and working hard.

Yet when I spend time at the Crimson Care Collaborative or at the primary care clinic that occupied my Wednesday afternoons for a year, I am reminded of what draws me to this field — patients like the soft-spoken college student who came to see us at CCC because his volatile digestive tract made it hard for him to go to class, let alone work his two side jobs. The diagnosis was potentially life-altering, and it was our job to piece together his story, to explain what we were thinking, and to arrange for him to get the lab tests and the colonoscopy which ultimately showed (thank goodness) that his condition wouldn’t require lengthy hospital stays and could be treated, with close attention, through outpatient visits.

This is what makes primary care interesting — relationships with patients, the intrigue of new diagnoses, and the challenge of coordinating and optimizing care.

Ganguli during her rotation in Guatemala.

We know that the US health care system needs more primary care doctors as the number of practitioners entering and staying in the field dwindles and the number of patients increases — more than 30 million are expected to get insurance through the new health care law.

Last September,Ìýthe American Association of Medical Colleges that “there will be 45,000 too few primary care physicians — and a shortage of 46,000 surgeons and medical specialists — in the next decade.”

In response, since 2000 nearly two dozen new medical schools Ìýor are being planned, for the first time in decades. The health overhaul seeks to entice more medical school graduates to fill these roles by redistributing unused residency training spots to primary care and offering new programs to repay the loans of graduates who work in underserved areas. Researchers at the George Washington University School of Medicine and Health Sciences have even introduced a for medical schools based on fulfilling the so-called “social mission,” which includes producing a certain number of primary care doctors.

But reducing the primary care shortage to a problem of supply, demand, and geography misses a critical point: that answering the nation’s workforce needs means more than mass-producing more doctors and nurses; it requires training practitioners who can deliver the kind of care our country requires.

For one thing, the benefits of loan reduction programs are quickly lapped by the margin of hundreds of thousands of dollars in income that specialists gain each year. A better way to encourage medical students to enter primary care is to make it more fulfilling to practice, and not just by adjusting payment structures (though this is important). The key is to expose future doctors to primary care early and to teach the skills needed by all doctors (but especially those in primary care): teamwork and a dynamic understanding of health care systems.

Historically, these skills have been given short shrift in medical schools.

I had little formal exposure to my future health care colleagues throughout medical school; I had no idea, for example, what physician assistants did and how they trained. I only found out when one morning in my third year of medical school I asked a physician assistant joining us for morning rounds because I was curious and frankly, embarrassed by my ignorance.

As I moved between rotations in surgery, pediatrics, and neurology, my charge was to fit in. So it was hard not to adopt the half-joking superiority over other specialties espoused by some of the residents and senior doctors with whom I worked.

I’d hear hospitalists deriding hastily written patient notes from emergency medicine doctors, and those emergency doctors griping about primary care doctors who sent their patients to the emergency room without having seen them first. There were perfectly good explanations for brief notes and unscreened referrals (in short, lack of time), but loyalty to my team-of-the-moment had to trump my sympathies with other fields, so I was wary of speaking up. At the same time, while I called the doctors I worked with my “teammates,” I had little idea how to make the most of these relationships or what to do if they went sour. But as my friends in business school tell me, this may be a teachable skill.

Doctors need to be taught not only how to manage teams, but when to let others take charge, said Dr. Robert Kocher, former member of the National Economic Council under President Barack Obama and special assistant to Obama on health care. “We need doctors who work flawlessly and without ego with nurses, [nurse practitioners], physician assistants ” he said in an interview.

We also need to understand the health care systemÌý– not just the history of Medicare, but the ins and outs of billing, malpractice, and quality measuresÌý– so that we can effectively work within, and on, this system. Student-run clinics are one way to do this. At the Crimson Care Collaborative, we learned to make real-time improvements in the way we deliver care that would be impossible at a large hospital center. There are plenty of other promising ideas.

Medical students at the partner with physical therapy and nursing students in anatomy lab, early in their training. At the University of Pennsylvania, students visit the to learn how car manufacturing standards can be applied to health care. At and , medical students can enroll in a primary care track in a rural setting that is dedicated to skills like teamwork and quality improvement. Harvard Medical School’s promises opportunities for students to work with clinicians on practice-improvement projects.

As the realities of our flawed health care system are brought to the forefront, primary care is becoming the purview of trainees interested in a broad perspective of this system and the desire to improve it. If we’re equipped with the skills to do this, I believe more of us will not only choose primary care, but also will practice it better.

Ishani Ganguli is a freelance journalist and a fifth year medical student at Harvard Medical School. She is a member of

,Ìý a Boston-based non-profit organization that promotes innovation in primary care training and delivery.

This <a target="_blank" href="/health-industry/ishani-ganguli-primary-care/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

The man was a grocery store clerk — an essential worker — and the sole earner for his family. A 14-day isolation period would put him at risk of getting fired or not having enough money to make rent that month. But he had just developed classic COVID-19 symptoms, and many others around him in Chelsea, Massachusetts, had confirmed cases. Even with the negative test, his chances of having the disease were too high to dismiss.

For many Americans, including clinicians like Chu, who specializes in primary care and infectious disease at Massachusetts General Hospital, the pandemic has forced difficult conversations about the limits of medical tests. It has also revealed the catastrophic harms of failing to recognize those limits.

“People think a positive test equals disease and a negative test equals not disease,” said Dr. , who heads the general medicine division at Memorial Sloan Kettering Cancer Center in New York City. “We’ve seen the damage of that in so many ways with COVID.”

National COVID test shortages have emphasized testing’s critical role in containing and mitigating the pandemic, but these inconvenient truths remain: A test result is rarely a definitive answer, but instead a single clue at one point in time, to be appraised alongside other clues like symptoms and exposure to those with confirmed cases. The result itself may be falsely positive or negative, or may show an abnormality that doesn’t matter. And even an accurate, meaningful test result is useless (or worse) unless it’s acted on appropriately.

These lessons are not unique to COVID-19.

Last year, David Albanese logged in to the online patient portal for his primary care doctor’s office and discovered that his routine screening test for the hepatitis C virus showed a positive result.

“I never considered myself somebody who’s in a high-risk category,” said the 34-year-old Boston-area college administrator and adjunct history professor. “But I just know that for a couple of days, I was really, really anxious about this test. I didn’t know if I should be behaving differently based on it.”

Within days, a confirmatory test showed Albanese did not actually have the potentially severe yet curable liver infection. Still, the memory of that false positive result gave him a new perspective on testing writ large. He had been skeptical of recommendations shifting breast cancer screening to older ages to reduce the psychological toll of false positives, but he said they made more sense after his own testing drama.

“‘Isn’t it better to do the screening regardless?’” he said he used to think. “Now I realize it is a little more complicated.”

These false positives are especially common for screening tests like hepatitis C antibody tests and mammograms that look for medical problems in healthy people without symptoms. They are designed to cast a wide net that catches more people with the disease, known as the test’s sensitivity, but also risks catching some without it, which lowers what is known as the test’s specificity.

Though some degree of uncertainty is inherent in all medical decisions, clinicians often fail to share this with patients because it’s complicated to explain and unsettling and leaves doctors vulnerable to seeming uninformed, said Korenstein. What’s more, doctors are trained to seek definitive answers and can themselves struggle to think in probabilities.

“High-tech diagnostic testing has led to this mirage of certainty,” said Korenstein. “Back in the day before there were MRIs and what not, I think, doctors were more cognizant of how often they were uncertain.”

Enter COVID. Coupled with genuine uncertainty about an emerging disease and a political environment that has sown misinformation and rendered science partisan, the nuances of testing are too often lost at a time when they are particularly crucial to convey.

Dr. , who specializes in infectious disease at the University of Nebraska Medical Center, was concerned to see Nebraskans tested at statewide facilities get “inconsistent results without a lot of guidance or explanation about what these results might mean.” When she offers COVID testing, she said, she approaches it as she does any other medical decision, starting with a simple question: “What do you want to learn from this test?”

To answer this, it helps to know something about how coronavirus tests work and how well they do their jobs.

Many of the available tests are meant to tell you if you’re infected right now. For example, polymerase chain reaction tests like the one Chu’s patient received detect small traces of genetic material from the virus. But by some estimates, those tests have a false negative rate of up to 30%, meaning . This rate also varies based on who collects the sample, from which part of the body and when in the course of a possible infection.

Antigen tests look for viral proteins and are faster to analyze than the PCR, but also less accurate.

To know if you’ve already had COVID-19, the closest you can get is the COVID antibody test. But the too-common interpretation is black and white: I had COVID, or I didn’t. Here, again, the reality is more nuanced. The test checks your blood for antibodies — your immune system’s soldiers in the fight against the coronavirus. A negative antibody test could mean you were never infected with SARS-CoV-2, or it could mean that you’re currently infected but haven’t yet built up that army, or that these defenses have already faded away.

A positive test, on the other hand, may have mistakenly detected antibodies to another, similar-looking virus. And even if the test correctly shows you had COVID-19, it’s not yet clear if this means you’re protected from reinfection.

Yet, these shades of gray are difficult to internalize. Roy Avellaneda, the 49-year-old president of the Chelsea City Council, got the antibody test out of curiosity and could not help but see his positive result as what he called an immunity pass. “I can act a little bit cavalier with it now,” he said. “Yes, I’ll continue to wear a mask and so forth, but the fear is gone.”

Korenstein said that’s a common though worrisome reaction. “It’s really hard to expect the public to have a more nuanced understanding when even doctors don’t,” she said.

Some of the uncertainty around COVID testing has abated as researchers learn more about the new disease. Early in the pandemic, health care providers retested patients with confirmed cases, looking for a negative PCR test to prove they were no longer infectious. But soon, epidemiologists discovered that a COVID patient rarely infected others 10 or more days after first developing symptoms (or 20, in severe cases), even if the PCR test was picking up traces of the — presumably dead — virus weeks or even months after initial infection. So the Centers for Disease Control and Prevention and health systems adjusted their policies to clear patients on the basis of time rather than a negative test.

But while the desire for certainty in coronavirus testing is magnified by the rampant uncertainty in other facets of pandemic life, this is simply not something most medical tests can provide.

This <a target="_blank" href="/public-health/how-covid-19-highlights-the-uncertainty-of-medical-testing/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

This is part of an occasional series, First Person.

Ganguli (Katherine Lambert)

The clinic starts at 5 p.m. sharp with a team huddle in the conference room. A black plastic tray of stale bagel halves and crusted cantaloupe sits on the table, remnants of a breakfast meeting, but despite our medical-student hunger, we focus on the task at hand.

At 5:15, patients start to arrive. Their paths have been carefully choreographed from waiting room to exam table, lab to social services. Our schedules, through vigorous debate, have been set to five-minute time slots and annotated in flow charts. The first- and second-year medical students take blood pressures and interview the patients. The senior students finish the exam and present each patient’s case — from poison ivy to possible kidney failure — to the supervising doctor, using practice guidelines printed in our thick orientation packets.

Other students fill in as patient coordinators, social workers, and lab directors, while the research and quality assurance team tracks data on patients’ health needs and wait times. The M.D./MBA candidates in the group designed the clinic’s business model with the goal of self-sustainability, but for now, we simply do our best to take care of our patients.

Each Tuesday evening, the internal medicine practice at lends its facilities to Harvard Medical School’s new student-faculty Ìý— the Crimson Care Collaborative (CCC). Medical schools across the country have similar student-run clinics, some decades old. More than a chance to play doctor, the clinic is a hands-on lesson in practicing primary care, the sort that forms the cornerstone of the “accountable care organizations” or “patient-centered medical homes” encouraged by the federal health overhaul law.

This evolving conception of primary care requires doctors and other primary health care providers to work in teams and to be creative about how they deliver care. Lawmakers have come to realize that it is critical for both improving our nation’s health and saving our wallets. Now medical training needs to change in kind.

My initial regard for primary care when I entered Harvard Medical SchoolÌýhas been distorted by frustrations I hear from practicing doctors and the not-so-subtle lure of a “lifestyle career” alternative, my putative reward for being smart and working hard.

Yet when I spend time at the Crimson Care Collaborative or at the primary care clinic that occupied my Wednesday afternoons for a year, I am reminded of what draws me to this field — patients like the soft-spoken college student who came to see us at CCC because his volatile digestive tract made it hard for him to go to class, let alone work his two side jobs. The diagnosis was potentially life-altering, and it was our job to piece together his story, to explain what we were thinking, and to arrange for him to get the lab tests and the colonoscopy which ultimately showed (thank goodness) that his condition wouldn’t require lengthy hospital stays and could be treated, with close attention, through outpatient visits.

This is what makes primary care interesting — relationships with patients, the intrigue of new diagnoses, and the challenge of coordinating and optimizing care.

Ganguli during her rotation in Guatemala.

We know that the US health care system needs more primary care doctors as the number of practitioners entering and staying in the field dwindles and the number of patients increases — more than 30 million are expected to get insurance through the new health care law.

Last September,Ìýthe American Association of Medical Colleges that “there will be 45,000 too few primary care physicians — and a shortage of 46,000 surgeons and medical specialists — in the next decade.”

In response, since 2000 nearly two dozen new medical schools Ìýor are being planned, for the first time in decades. The health overhaul seeks to entice more medical school graduates to fill these roles by redistributing unused residency training spots to primary care and offering new programs to repay the loans of graduates who work in underserved areas. Researchers at the George Washington University School of Medicine and Health Sciences have even introduced a for medical schools based on fulfilling the so-called “social mission,” which includes producing a certain number of primary care doctors.

But reducing the primary care shortage to a problem of supply, demand, and geography misses a critical point: that answering the nation’s workforce needs means more than mass-producing more doctors and nurses; it requires training practitioners who can deliver the kind of care our country requires.

For one thing, the benefits of loan reduction programs are quickly lapped by the margin of hundreds of thousands of dollars in income that specialists gain each year. A better way to encourage medical students to enter primary care is to make it more fulfilling to practice, and not just by adjusting payment structures (though this is important). The key is to expose future doctors to primary care early and to teach the skills needed by all doctors (but especially those in primary care): teamwork and a dynamic understanding of health care systems.

Historically, these skills have been given short shrift in medical schools.

I had little formal exposure to my future health care colleagues throughout medical school; I had no idea, for example, what physician assistants did and how they trained. I only found out when one morning in my third year of medical school I asked a physician assistant joining us for morning rounds because I was curious and frankly, embarrassed by my ignorance.

As I moved between rotations in surgery, pediatrics, and neurology, my charge was to fit in. So it was hard not to adopt the half-joking superiority over other specialties espoused by some of the residents and senior doctors with whom I worked.

I’d hear hospitalists deriding hastily written patient notes from emergency medicine doctors, and those emergency doctors griping about primary care doctors who sent their patients to the emergency room without having seen them first. There were perfectly good explanations for brief notes and unscreened referrals (in short, lack of time), but loyalty to my team-of-the-moment had to trump my sympathies with other fields, so I was wary of speaking up. At the same time, while I called the doctors I worked with my “teammates,” I had little idea how to make the most of these relationships or what to do if they went sour. But as my friends in business school tell me, this may be a teachable skill.

Doctors need to be taught not only how to manage teams, but when to let others take charge, said Dr. Robert Kocher, former member of the National Economic Council under President Barack Obama and special assistant to Obama on health care. “We need doctors who work flawlessly and without ego with nurses, [nurse practitioners], physician assistants ” he said in an interview.

We also need to understand the health care systemÌý– not just the history of Medicare, but the ins and outs of billing, malpractice, and quality measuresÌý– so that we can effectively work within, and on, this system. Student-run clinics are one way to do this. At the Crimson Care Collaborative, we learned to make real-time improvements in the way we deliver care that would be impossible at a large hospital center. There are plenty of other promising ideas.

Medical students at the partner with physical therapy and nursing students in anatomy lab, early in their training. At the University of Pennsylvania, students visit the to learn how car manufacturing standards can be applied to health care. At and , medical students can enroll in a primary care track in a rural setting that is dedicated to skills like teamwork and quality improvement. Harvard Medical School’s promises opportunities for students to work with clinicians on practice-improvement projects.

As the realities of our flawed health care system are brought to the forefront, primary care is becoming the purview of trainees interested in a broad perspective of this system and the desire to improve it. If we’re equipped with the skills to do this, I believe more of us will not only choose primary care, but also will practice it better.

Ishani Ganguli is a freelance journalist and a fifth year medical student at Harvard Medical School. She is a member of

,Ìý a Boston-based non-profit organization that promotes innovation in primary care training and delivery.

This <a target="_blank" href="/health-industry/ishani-ganguli-primary-care/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">