One of the clinic’s regular visitors, a man with heavy black arrows tattooed on his arms, waited on the sidewalk to get clean needles.

“I’m Arrow,” he said, introducing himself. “Pleasure.”

This mobile unit in Miami-Dade County is part of the IDEA Exchange, the only legal needle exchange program operating in the state. But Florida’s Republican governor, Ron DeSantis, signed a new law last week that aims to change that.

Needle exchanges have been legal in many other states for decades, but Southern, Republican-led states like Florida have only recently started to adopt this public health intervention.

The timing of the statewide legalization of needle exchanges comes as Florida grapples with a huge heroin and fentanyl problem. When people share dirty needles to inject drugs, it puts them at high risk for spreading bloodborne infections like HIV and hepatitis C. For years, Florida has had America’s highest rates of HIV.

Even so, Arrow said, he and every user he knew always put the drugs first. Clean needles were an afterthought.

“Every once in a while, I did use someone else’s and that was a thrill ride — wondering whether or not I was going to catch anything. But I’m blessed; I’m 57 and I don’t have anything,” Arrow told a reporter at the mobile clinic over a year ago.

Kaiser Health News agreed not to use his full name because of his illegal drug use.

“Now I can shoot with a clean needle every time,” he said.

The Miami Experiment

According to the , needle exchanges prevent the spread of viruses among users of injection drugs.

But the advocates who want to offer needle exchanges face challenges. For example, carrying around loads of needles to hand out without prescriptions can violate drug paraphernalia laws.

Many states mapped out legal frameworks decades ago to allow needle exchanges as a public health intervention. But in Florida, it was illegal to operate exchanges. Then, in 2016, the state legislature gave Miami-Dade County temporary permission to pilot a needle exchange program for five years.

“This is more than just a needle exchange,” said Democratic state Sen. Oscar Braynon.

“This has become a roving triage and health center.”

In three years of operation, Miami’s pilot program has pulled more than a quarter-million used needles out of circulation, according to reports the program filed with the Florida Department of Health. By handing out Narcan — a — the exchange has prevented more than a thousand overdoses. The program also offers clients testing for HIV and hepatitis C. Finally, the program connects people to medical care and drug rehab.

This year, Braynon introduced to allow the rest of Florida’s counties to authorize similar programs.

“We have made it so easy for people to get into HIV care now, and we have so many people who we never would have known were infected — and would have infected countless other people — who are on their medications,” said Dr. Hansel Tookes, who heads Miami’s needle exchange pilot program.

Tookes was in Tallahassee, the state capital, in May when the expansion bill passed its final vote — a long shot in the conservative-dominated legislature that nonetheless passed by an overwhelming margin. He said he spent the return flight home to Miami staring out the window.

“I looked down at Florida the entire ride,” he said, “and I just had this overwhelming feeling like, ‘Oh, my God, we just did the impossible and we’re going to save so many people in this state.'”

Why Harm Reduction Trumped Politics

Six years ago, Republican state Sen. Rob Bradley cast a “no” vote after considering a proposal for needle exchanges.

“You’re trying to make sure the person has a clean needle, which is outweighing the idea of the person breaking the law,” he declared in 2013.

This is the primary objection of conservative lawmakers: the concern that these programs promote illegal drug abuse. Responding to this skepticism with data has been central to changing lawmakers’ minds.

Decades of research shows that needle exchanges do not encourage drug abuse, and that they lower other health risks for people who are vulnerable and often hard to reach. It’s part of a public health approach known as “harm reduction.”

In Miami, the needle exchange pilot project has also earned the support of law enforcement.

Officers say it’s a relief to know more injection drug users are keeping their syringes in special , provided by the exchange, to safely dispose of dirty needles.

“Now, for our officers, when they’re doing a pat-down … that sharps container is really protecting you from a loose needle,” said Eldys Diaz, executive officer to the Miami police chief. “That’s an extraordinary source of comfort for us.”

This year, when Bradley heard discussion of the needle exchange bill again, he had a different response.

“I just want to say, when I started my career in the Senate, I voted against the pilot project — and I was wrong,” he said as he voted for the bill this time. “And the results speak for themselves. It’s very good public policy.”

The bill passed unanimously in the Florida Senate and by a 111-3 vote in the Florida House. It took effect Monday.

Arrow Points To His Future

If it weren’t for the tattoos running down his arms, it would be hard today to recognize Arrow as the man who once slept under highway overpasses. His skin is now clear, and he has some meat on his bones. He looks healthier during a visit to a clinic where needle exchange clients get follow-up care, but it’s been a rough year.

In May of last year, Arrow’s girlfriend died from a heart infection — a serious condition that can happen to people who inject drugs. After that, Arrow said, he overdosed on purpose. Narcan from the needle exchange brought him back.

But he kept using.

Arrow said he doesn’t remember a lot from that period but does remember using so much heroin that he ran out of fresh needles between visits to the exchange. So he grabbed other people’s used needles.

And then he tested positive for HIV and hepatitis C.

Tookes and his colleagues threw Arrow another life raft: They got him an inpatient drug treatment bed.

Now Arrow sports a string of keychains from Narcotics Anonymous.

“My chain of sobriety,” he said of the links. “I got 30-days, 60-days and 90-days chips,” he said.

Arrow’s HIV is under control. And he connected with health services for people living with HIV, including getting medication that cured his hepatitis C.

Now, he’s focused on staying sober, one day at a time. He has been sober for about six months.

Tookes, Braynon and other supporters hope additional needle exchanges across Florida will give more people the chance to recover from addiction — and protect themselves from needle-borne illnesses.

This story is part of a partnership that includes , and Kaiser Health News.

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

When Florida Gov. Rick Scott made free Zika testing available to all pregnant Floridians through the , I was one of the more than 2,200 women who took him up on the offer.

My station’s main studios are five blocks south of the Wynwood Zika , an area that authorities are recommending pregnant women avoid (though the advisory was  to a less dire warning on Monday). As it turned out, I had been inside the suspected transmission zone before we knew the risks.

So on the morning of Aug. 12, I went to my obstetrician’s office, gave blood and urine samples and was told that it would take about seven to 10 business days to get my results.

Four and a half weeks later, I was still waiting. I had plenty of company.

My colleague has been helping me cover the story, whenever it veers into an area where the Centers for Disease Control and Prevention has advised pregnant women to avoid. Stein covered a Miami Beach town hall I didn’t attend. There, she met Joseph Magazine, who pleaded with officials to help his wife get her Zika test results back. She was more than five months pregnant, had experienced Zika-like symptoms a month earlier, and was waiting to hear if she had been infected.

Press releases and other communications from the Florida health department officials have repeatedly insisted it takes one to two weeks to get results.

But at another town hall, after some pushing, Dr. Lillian Rivera, head of the Miami-Dade County Department of Health, said women may wait longer. “It could be four weeks, it could be five weeks,” Rivera said. “We are preparing them for that.”

Rivera was quick to point out complete testing can take a long time, depending on the first round of results. That’s because the Zika test for a pregnant woman can actually be . The first test is to see if she has an active infection. If that’s negative, there’s a test to see if she’s had the virus in the past 12 weeks. If that’s negative, case closed.

But if the second test is positive, or inconclusive somehow, then the woman’s samples are sent to the CDC for an even more specialized test to confirm it’s Zika and not dengue or another virus that can cause false positives.

As of last week, Florida had sent 174 tests to the CDC for clarification, including the tests of people who aren’t pregnant. That total doesn’t explain the backlog that snared me.

Obstetrician , with the University of Miami and Jackson Health System, said it’s helpful that all pregnant women in Florida can be tested. But getting timely test results is important, too.

“If someone’s early first trimester or second trimester and we delay disclosure because we don’t have a result by two weeks, four weeks, six weeks, eight weeks — that may be long enough for them to be out of the window of being able to terminate that pregnancy,” she said.

Florida law restricts abortion access . Later-term abortions are also more complicated procedures and more emotionally fraught for parents.

Delays in testing results can change the way doctors screen the newborns of women who are still waiting on their Zika test results, Curry said. “Do we do more invasive, more aggressive testing? Do we do blood tests and urine tests and a spinal tap on the child?”

I spoke to Curry after I had been waiting more than a month for my results and that image jars me: a spinal tap on my newborn because of a bureaucratic backlog on test results?

This is when I started to get nervous and angry.

Zonnia Knight, a fellow pregnant South Floridian, compares the waiting period for the test results to being told there are spiders in the room.

“You find yourself scratching, or looking around, swatting off ghosts and stuff,” she said. “To me, there was a mosquito everywhere.”

Knight waited three weeks with those ghosts before her Zika results came back. She was negative.

The bottleneck appears to be getting us back the reports.

Dr. David Andrews

Another pregnant woman, Tracy Towle Humphrey, went to a private lab for her test and bypassed the health department. Without insurance, those tests can range from about $150 to almost $800.

Humphrey’s insurance covered it, though. Within one week, she got her negative results back.

But she said for that week, she had trouble sleeping. She would wake up in the middle of the night “thinking, ‘Oh my gosh, what if it’s positive? What are we going to do?'”

After four and a half weeks, I called the Florida Department of Health.

I didn’t identify myself as a reporter. I was afraid that might affect my ability to get information on my own records. I was repeatedly told the health department doesn’t give out results over the phone and they’ll be sent to my doctor.

But after explaining a couple of times that I just wanted to know where my test was, I ended up talking to someone in the local epidemiology department who said she might be able to look up my test. She did, and I learned my test results were completed in the state lab in Jacksonville on Aug. 19 and Aug. 26.

So my completed tests were sitting there, I learned, for more than two weeks, and neither I nor my doctor had been informed of the results.

“Your story is completely consistent with my understanding,” said Dr. David Andrews, who runs the pathology laboratories at Jackson Health System and is on faculty at the University of Miami’s med school.

He told me he’s had upward of 900 pregnant women waiting on their Zika test results. The backlog is so large, he can’t even make a good calculation on the average turnaround time. “It is my sense that most of these specimens have been tested and are being tested in a reasonable amount of time, but the bottleneck appears to be getting us back the reports,” Andrews said.

Mara Gambineri, a spokesperson for Florida’s health department, sent an email that didn’t specifically respond to my question about why it takes so long to release results once the tests are completed:

“The department has been working with area hospitals and providers, particularly in Miami-Dade County, to ensure doctors are receiving test results quickly and communicating the information with their patients. We continue to work to improve and streamline the process.”

Another spokesperson named Sarah Revell said in the same exchange of emails:

“The department continues to dedicate significant resources to our public health labs and we have contracted with a private lab to assist with processing Zika tests quickly and accurately. Florida is the first and only state to offer such extensive resources to pregnant women and we are constantly working to improve our process.”

On Wednesday, Sept. 14, Gov. Scott announced the CDC is sending seven more people to help out with labs and testing “in order to ensure pregnant women get results back faster.”

On Friday, Sept. 16, a few hours after WLRN aired a story about the testing backlog and my wait, I got a call from the county health department asking for my doctor’s contact information. They released my test results to my obstetrician, who shared them with me: They are negative.

Kate Stein contributed to this report. This story is part of a partnership that includes , and Kaiser Health News.

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

“I believe that this contract honors and dignifies what you do every single day,” he told the school board members. It included bonuses for most teachers and it settled how to handle health care expenses after yet another year of rising costs.

“We know exactly what the district pays out in terms of claims, because we are the insurance company. There’s no profit to be made,” he said.

Like most large employers, the Miami-Dade school district is . It bears the financial risk of covering its own employees.

The school board’s reaction to the health care costs in the new contract was incredulous. They are an elected board and didn’t look forward to telling the teachers their prices were still going to go up. One board member after another questioned the rise in prices.

“Do we sit with our employees, knowing what their salaries are, and help them carve out the best options insurance-wise?” one asked. “Twenty-seven hundred more for his family’s health — can you comment on that?” asked another. Yet another lamented, “Our employees are tired of hearing about rising health care costs.”

This was not the conversation the superintendent expected.

“I thought we were coming here today [to] first and foremost celebrate something pretty remarkable,” he said.

Now, a year later with another new contract, the school board is still grappling with health care costs. Teacher contributions to insurance will mostly stay the same, but it means the district will absorb another 4 percent increase in costs.

Fedrick Ingram is head of the Miami-Dade County teacher’s union, which represents nearly 15,000 members.

“Our salaries have not gone up in the same way that health care costs have gone up,” he explains. So he’s been urging the school district to figure out where the money is going.

“We have to know who’s driving up costs,” he says. “What’s going to affect the bottom line for our premium costs, and what is actually contributing to that.”

Turns out, that is incredibly . But it’s a conversation more businesses should be having, says Uwe Reinhardt of Princeton University.

Businesses and employees need to stop taking for granted that rising health care costs are inevitable because they make tradeoffs, Reinhardt says.

“Employees actually pay for what they think is company-provided insurance, by lower wages,” he says. But it’s so hard to get costs under control because the actual prices are secret.

Self-insured organizations like Miami-Dade County schools have to hire an insurance company to manage the claims process and negotiate rates with hospitals and doctors. But insurers and providers keep the rates secret, even from those employers hiring them.

Carvalho’s right: The district knows exactly what it pays overall for health care claims. What it doesn’t know is how much it’s paying to any one hospital or provider for a given service.

That means it doesn’t know who’s the most expensive provider, or who is the cheapest. That may drive prices higher for employees, Reinhardt says.

“It’s almost like blindfolding people, shoving them into Macy’s and saying, ‘Buy efficiently for a shirt.’ ” Reinhardt says. “Well, you come out with a pair of shorts.”

The school district is subject to the state’s open records laws, but Cigna, the insurance carrier they use for employees, refused to share accounts of what was actually paid out, citing trade secrets. Even though the county school district, which is taxpayer-funded, takes on that risk, it’s not allowed to see the contracted prices.

The district is seeking ways to get around the legal obstacles. It’s planning to shop for a service that can work with its limited and at least figure out average costs. Ideally, district officials say, they’d like to know enough about costs to offer incentives for employees who choose less expensive options.

Until there’s more transparency, Miami-Dade teacher’s union member, Cheryl Collier thinks the situation would offend even her second-graders.

“They would be angry that they are being forced pay for something, not really fully understanding the value of what they’re paying for,” she says.

It’s a lesson the school district and other employers are starting to learn.

This story is part of a partnership that includes , and Kaiser Health News.

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

Believe it or not, that’s the easy part compared to figuring out what the overall cost of health care is.

Sal Morales of Miami bought insurance in March during the ACA’s first enrollment period on .

“I got my cards and it was like amazing,” Morales says, “like if I got an American Express Platinum card. That’s how I felt.”

Morales was unemployed at the time. Money was tight. And he knew he needed regular doctor visits to manage his high blood pressure. He diligently researched what he would get for the price before settling on a plan.

“Instead of me paying $560 [a month] for COBRA, I found out that I would have insurance for $145. I have a network deductible of $500,” Morales says. “My first three visits to a primary care physician, they’re zero dollars. Then it’s $5 out of my pocket.”

Morales understands his end of the health care equation, but what he sees doesn’t necessarily reflect what gets paid to doctors and hospitals for his care, says , president of the Florida Hospital Association.

Here’s how he breaks it down: “There’s one party, the hospital who provides the service. There’s a second party, the patient, who receives the service. And there’s a third party, the insurance, who pays for the service.”

That third part is where health care pricing gets really squirrelly.

Every hospital has its own “master list” of charges for different services. Those charges are different from hospital to hospital.

But insurance companies don’t pay those listed charges. The listed charges are almost fiction. Instead, each insurer negotiates for lower prices with each hospital and doctor on every plan. And insurers can have multiple plans with multiple agreements for the same hospitals or doctors.

Even if two patients have the same insurer, if their plans are different, the insurer may pay the doctor differently for the same care for each of the patients.

All of this means there are about as many pricetags for that hypertension checkup as there are insurers and providers.

“For an individual consumer I am completely sympathetic that it’s very confusing,” says Dr. Ezekiel Emanuel, who was an adviser to the president during the drafting of the health law and is now a health policy expert at the University of Pennsylvania.

“There are at least six different prices for a hospital day. And then there’s the cost of actually delivering the service, which, for most of these things, even hospitals don’t know what that is. So when you say, ‘What’s the price?’ It’s almost a meaningless question, because there [are] all these different prices.”

Those negotiated rates—the prices insurance companies really pay hospitals—are treated like trade secrets. Insurers and many hospitals don’t want their competitors to know what  the payments are

It is only on an individual basis that people can see the prices their insurer paid for their care. And it’s after the care has been delivered and only if the person is already insured.

It’s buried in a statement called an explanation of benefits. These are the letters from insurers that look like a bill but say “this is not a bill.”

Efrain Monzon helps patients interpret those explanations for , the largest insurance company in the state of Florida.

“We’re identifying the procedure, we’re identifying the provider, the date of service and then making sure the amount, the member responsibility has to be in there,” Monzon says.

Wedged into that statement somewhere between the billing code and the member deductible, is a column for the amount paid.

This is the secret number the insurance company and the provider have worked into their contract, says Monzon. The industry terms are usually “adjusted rate” or “negotiated rate.”

In Florida Blue’s explanation of benefits to patients, it’s called simply “amount paid.”

To get a clearer sense of what health care costs, someone would have to collect enough of those statements from patients at all different hospitals with all different insurance.

There are companies and trying to do just that around the country. And Massachusetts has a law that says insurers some of these prices in a way that is accessible to patients.

But so far, that’s not happening in South Florida.

This story is part of a partnership that includes , the , and Kaiser Health News.

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .