Noise can damage your heart as well as your hearing, but there are ways to measure your exposure and reduce your risk.Chronic noise exposure is not just a nuisance, scientists say. It’s a health risk.In fact, mounting research suggests that, as average noise levels climb, so do the risks of overreactions in your body that contribute to cardiovascular disease and other health issues.For a project on the harmful effects of noise, New York Times journalists used a Larson Davis Sound Level Meter, a professional sound measurement device, to assess noise exposure in communities around the United States. But you don’t need a fancy device to get a sense of your own noise exposure.Try this websiteYou can search your ZIP code in an online noise map developed by the Transportation Department. But keep in mind that the map uses 2018 data and accounts only for transport-related noise — and, like all modeled data, it is based on approximations — so it pales in comparison with on-the-ground measurements.But if you have 15 minutes to spare, there’s a better way to check noise exposure wherever you live, work or gather.Download this appThe NIOSH Sound Level Meter app for iOS, designed by the National Institute for Occupational Safety and Health at the Centers for Disease Control and Prevention, was developed by acoustics engineers and medical experts to help workers prevent hearing loss, but its measurements are just as helpful for detecting systemic risks.The app’s accuracy was verified in an acoustics laboratory and published in a scientific journal. Note that it measures sound energy — it does not record or share audio.(The app isn’t available on Android devices, developers said, because the fragmented Android device marketplace made it too difficult to verify the app’s accuracy in the lab. There are other apps available — like Decibel Pro, SPL Meter and Decibel X — but those were not developed at the C.D.C.)Record a 15-minute averageThe NIOSH Sound Level Meter app gathers noise readings immediately, but needs several minutes to collect accurate averages.NIOSHWhen you open the app, you’ll see noise levels immediately in large numerals. But, by pressing the “play” icon, the app will begin to collect measurements over time. Leave the app open for several minutes — the “Total Run Time” line tracks how long it has been collecting sound readings.When it comes to interpreting your sound exposure, the decibel figure on the “LAeq” line will be the most useful. It shows the average sound pressure over the given time period — and if you ran the app for a full 24 hours, the metric would be comparable with the metric used in many studies.A 15-minute recording is likely to represent the average noise exposure for the hour, said Edmund Seto, an associate professor of environmental health at the University of Washington who is studying noise across America. If you aren’t using a calibrated external microphone for optimal readings — and we assume that you’re not — the developers say running repeated tests in the same space should offer you a representative sample.Be sure to press the “reset” button — the one with the return arrow — between tests. A more detailed user manual can be found here.What those numbers meanThe health risks of noise exposure can be hard to interpret since they differ based on source and sound qualities.As a general rule of thumb, the World Health Organization considers average road traffic noise levels above 53 decibels and average aircraft noise levels above 45 dB to be associated with adverse health outcomes, though their metrics are weighted slightly differently than the average on your screen.Nighttime noise is considered particularly harmful because it can fragment your sleep and prompt a stress response, even if you don’t remember waking up. The W.H.O. has long recommended less than 30 dB of nighttime noise inside your bedroom for high-quality sleep.How to protect yourselfWithout major regulatory changes, outside noise levels are unlikely to change. Still, health experts say you can take some steps to protect yourself.Replace old windows with double-pane glass. You can apply foam insulation to noisy rooms — like those with whirring clothes dryers — to reduce their noise emissions.When it comes to nighttime noise, it’s best to sleep in rooms as far away from the roadway as possible and to invest in heavy window drapes and thick rugs to reduce vibration.Buy yourself some earplugs, too.Contribute your findings to researchIf you’d like to help researchers improve their noise models, add your measurements to the Noise Across America study portal at the University of Washington. Dr. Seto is eager to hear from you.

Noise is a vast — and largely unrecognized — threat to your health. The Times is collecting personal stories and noise measurements from readers like you.Noise affects everybody differently.Some city dwellers feel as if they’ve habituated to the commotion — until they try to fall asleep in the countryside, to the chorus of crickets. Other people live in rural communities that, once quiet, face the cacophony of bitcoin-mining operations.Still more have tried and failed to soundproof their homes, living at the mercy of a neighbor’s stereo, a gas-powered leaf blower or a straight-pipe motorcycle several blocks away.The New York Times explored the harmful effects of noise in a recent project that aimed to unpack the noise levels and sound qualities that can lead to long-term health consequences. Now, we want to hear about the role noise plays in your everyday life.We will not publish any part of your submission without contacting you first. We may use your contact information to follow up with you.

The NewsA federal appeals court on Monday temporarily blocked a lower court decision that overturned the Affordable Care Act’s requirement that all health plans fully cover certain preventive health services.The move by the U.S. Court of Appeals for the Fifth Circuit in New Orleans will put on hold a decision from March that had threatened insurance coverage for recommended services like depression screenings for teenagers and drugs that prevent transmission of H.I.V. The Justice Department had appealed the decision, and the appeals court’s stay will stand while the appeals process plays out.Why It Matters: Preventive health services are popular.The ruling earlier this spring overturned one of the most popular requirements of the Affordable Care Act by taking away the financial barriers to a range of preventive services. It had taken effect immediately nationwide and had the potential to affect roughly 150 million Americans enrolled in private health insurance, either through employer-sponsored plans or through the Obamacare marketplaces.While the case is under review, full coverage for preventive services will be legally required.Background: The Affordable Care Act under fire — again.Earlier this year, Judge Reed O’Connor of the Federal District Court for the Northern District of Texas ruled that insurers did not have to cover any of the services that had been recommended by the United States Preventive Services Task Force since 2010. His reasoning: The task force is not appointed by Congress and therefore did not have the constitutional authority to decide what services a health insurer must cover.That ruling had built upon previous ones: In 2018, Judge O’Connor had ruled that the A.C.A. was unconstitutional (though the Supreme Court later overturned that decision). Last September, he ruled that the A.C.A.’s mandate that employers cover a daily H.I.V. prevention pill called PrEP violated a company’s religious freedoms.What’s Next: A march toward the Supreme Court.For now, employers will still be required to provide no-cost coverage for preventive services. But the Fifth Circuit is conservative-leaning, and the case could eventually end up at the Supreme Court as yet another challenge to the Obamacare health law.

In a tight-knit town already skeptical of the government, the lack of concrete information, and the open-ended nature of the crisis, undergird anxiety.EAST PALESTINE, Ohio — When the railroad crossing gate lowered in front of Greg Mascher’s Chevy Tahoe, his youngest granddaughter shrank down in the back seat and pulled a worn American flag blanket over her eyes. She worried that the train was going to wreck — again.“Tell me when it’s all over, Papa,” his granddaughter, Raylix, 7, pleaded as the rail cars rumbled through — ones much like the Norfolk Southern cars that had derailed here almost three weeks earlier, resulting in a toxic spill that appeared to cause symptoms of chemical poisoning in hundreds of households.Mr. Mascher, 61, who is raising three granddaughters with his wife, Traci, had not sent them back to school since they had developed rashes, vomiting and headaches. He glanced at Raylix, still cowering under the blanket, in his rearview mirror.“When it’s all over, huh?” he sighed, adjusting the crucifix around his neck. “Not sure anybody can tell you girls that.”Mobile health clinics and camera crews have begun to pack up and leave this town of 4,700, but for the Mascher family and their neighbors, frightening questions remain: How could they know if they had been poisoned by the spill? Were toxins still lingering in the air, the water and the soil surrounding their houses? Would they develop lifelong health problems? And would the relatives who had evacuated the town — like Mr. Mascher’s daughter, her husband and their three daughters, cousins who are like sisters to Raylix — come back?On Thursday, the chief executive of Norfolk Southern, Alan H. Shaw, encountered more angry questions, when he appeared before a Senate committee. He told the panel he was “deeply sorry” for the impact of the derailment on East Palestine residents but insisted that “the air is safe to breathe and the water is safe to drink.”In fact, it could be months or longer, if ever, before health officials know for sure whether the symptoms suffered by East Palestine residents are directly linked to the derailment, and whether they could yield long-term effects. In a tight-knit town that is already skeptical of the government, the lack of concrete information undergirds the growing anxiety.Medical guidance is sparse. The long-awaited state health clinic sent to East Palestine weeks after the spill at first offered only questionnaires and did not have a doctor on hand. Local primary care physicians, booked for weeks, say that without more toxicology data, they aren’t equipped to diagnose chemical poisoning, so they are simply treating symptoms with ibuprofen and ointment.Cleanup work at the site of the Norfolk Southern train derailment late last month. Matt Freed/Associated Press“When you’re a physician, you have to call out that you just don’t know,” said Dr. James Kravec, an internist and the chief clinical officer of Mercy Health-Youngstown, which has a primary care practice in East Palestine. “With high blood pressure or diabetes, it’s pretty straightforward. Right now, doctors want to run a test — order something — and they can’t. That’s hard for them.”Toxicology experts say that children are of particular concern when chemicals are burned and disseminated into the air, because they typically breathe faster and have smaller lungs. A dose of toxins that is negligible to an adult could have a significant impact on a child, said Dr. Mary Prunicki, a Stanford researcher focused on the health effects of air pollutants. If one of the gases causes bronchospasm or inflammation of the airway, a child “has much less leeway than a healthy adult,” she said.The Mascher granddaughters are a prime example. The morning before the derailment, the three girls enjoyed their daily routine. Mr. Mascher’s daughter, Adyson Glavan — the girls’ Aunt Addy — dropped off her own three daughters at Mr. Mascher’s. He made breakfast for all six granddaughters while they fed the guinea pigs and practiced cartwheels in the front yard.That night, the train derailed, and two days later, as smoke billowed from the railroad tracks, all six girls developed runny noses and bronchitis-like coughs. Raylix, Kayton and Brayla — whom Mr. Mascher cares for — broke out in rashes. Two of Ms. Glavan’s daughters, Vivian and Vayda, began to vomit. The sprawling family loaded into two S.U.V.s to temporarily evacuate.Michael S. Regan, the head of the Environmental Protection Agency, said officials were “testing for everything that was on that train.” But, toxicology experts say, the chemical makeup of a spill changes over time as it ages and interacts with the atmosphere, the soil and the groundwater, creating copious new threats that cannot be easily profiled.Vinyl chloride, for example, the chemical that was carried in five of the cars, can cause toxic fumes made up of new compounds like carbon monoxide, hydrogen chloride and phosgene, a substance classified as a lethal chemical weapon in World War I, according to Dr. Prunicki. Burning vinyl chloride can also produce dioxins, which are known to cause cancer, infertility, Type 2 diabetes, ischemic heart disease and immune disorders.Medical guidance has been sparse, with the long-awaited state health clinic that finally arrived at first only offered questionnaires. And local doctors say that without more toxicology data, they can’t diagnose chemical poisoning.Brian Kaiser for The New York Times“There are hundreds of chemicals that could be at play at this point, and we absolutely have the tools in academia to test for most all of them,” said Dr. Kari Nadeau, the head of the environmental health department at Harvard, who studies the toxicological effects of smoke in air pollution, including burning plastics. But Congress allows the E.P.A. to monitor for only a limited list of contaminants in the environment, and even with approval, the bureaucratic process of validating and deploying each of the assays could take years.Instead, air monitors are hanging on stop signs and trees — wrapped in plastic bags to protect them from rain, an impediment that Dr. Nadeau called “concerning.”Another key force that is often overlooked in toxin surveillance: gravity. Even once the air and surface resources appear to be clear, chemicals tend to seep downward into soil and deep municipal water sources, even some that have previously tested safe, toxicologists say. And as water sources become diluted over time, toxin levels could simply fall below regulation thresholds, giving a false sense of purity.“With toxicology, it’s both the dose and the passage of time” that matter, said Dr. Nadeau, who also practices medicine and treats children with sensitivities. “We are only as good as our assays.”The Mascher family has been a fixture in East Palestine since Mr. Mascher’s great-great-grandfather opened a jewelry store in 1876 on Market Street, down by where Gorby’s sandwiches and an antique shop are now, and later became mayor. The granddaughters are eighth-generation residents. But on the night they returned from the evacuation, they also became an illustration of a painful reality: When trauma strikes, not everyone can flee.When Vivian, Ms. Glavan’s 8-year-old, broke out in new rashes, she turned her car around. Her household has since moved to Homeworth, Ohio, about 30 miles west.“You know I can’t bring them back there, Dad,” Ms. Glavan said to Mr. Mascher over the phone. He nodded silently.But Mr. Mascher, who relies on Social Security checks and is not in a position to move, feels trapped. “Who would want to buy this house?” he said. “Who would want to live in East Palestine now?”Mr. Mascher with his granddaughter, Kayton, outside his home. Mr. Mascher himself has suffered from loss of appetite and lack of sleep.Brian Kaiser for The New York TimesMr. Mascher finds himself with no appetite and unable to sleep, unsure of whether his granddaughters’ headaches and coughing are due to the flu or to a chemical poisoning that will worsen the longer they stay. He wonders whether raising the girls here could lead to birth defects for their own children later on.Indeed, while the physical health effects of the crisis are plagued with uncertainty, the mental health consequences are clearer.“What is happening in East Palestine has all the hallmarks of an environmental disaster that can lead to long-term mental health consequences,” said Dr. Salma Mohamed Hassan Abdalla, a researcher at Boston University who studied the impact of the 2014-16 water crisis in Flint, Mich., in which officials switched the source of the city’s water and then responded slowly to elevated lead levels and reports of sickness.The scene in East Palestine is reminiscent of Flint, where the authorities offered shifting narratives and thin assurances to low-income families who had few options but to stay and hope. There, as in East Palestine, pallets of bottled water were stacked onto porches as neighbors exchanged advice about how to safely brush their teeth and bathe their children.Almost one in four adults in Flint, Mich., met the criteria for post-traumatic stress disorder in the years following the water crisis, according to surveys, and many of them attributed the burden to worries about their children’s futures. Stress among caregivers was deeply intertwined with that among young people, who saw months of television ads for personal injury lawyers and political campaigns leveraging the crisis.“In a town like East Palestine, you have a lot of people already vulnerable because of socioeconomic status — already most susceptible to mental health issues — even before they’re hit with disaster,” Dr. Abdalla said. As the uncertainties mount, those groups are also the least likely to have access to support services. “I worry about increasing mental distress as time goes on.”When the fourth-grade girls’ basketball team finally gathered in the elementary school gymnasium for its first practice after the derailment, the court was still covered with cots, boot tracks and dusty debris left by the railroad cleanup crews who had encamped there. The players and their coaches, including Mr. Mascher, stood at half-court, hugged one another and cried.Mr. Mascher did not yet have the courage to tell Raylix that Ms. Glavan’s household wasn’t coming back to live in East Palestine. The railroad that cuts their town in half every 15 minutes has also split their family.A trampoline sat near one of the derailed train cars as crews worked on its burned remains.Brian Kaiser for The New York Times

Nearly all Americans over 65 got their initial Covid vaccines. But that immunity is waning, and this time, the government is offering far less support for new shots.PLEASANT HILL, Calif. — Bonnie Ronk is something of a public health matriarch at the Mt. Diablo Center for seniors in this liberal Northern California suburb.When Ms. Ronk, a great-grandmother whose red walker bears a sticker saying “El Jefe” (The Leader), tells her peers to pull their masks over their noses, they oblige. When she received both doses of the Covid vaccine and a booster and told others to do the same, they did.But even Ms. Ronk, 79, has not gotten the latest Covid booster, which was updated to protect against the Omicron variant and has been available since September. She said she didn’t know about it.Across the United States, where about 94 percent of people 65 and older had their initial Covid vaccines, only 36 percent have received the updated shot, known as the bivalent booster, according to data from the Centers for Disease Control and Prevention. Seniors have offered an array of explanations: They were unaware of it, unable to find it or unconvinced of its value.As the pandemic barrels into its third winter, and Covid hospitalizations and deaths climb once again, medical experts worry that there is no effective plan to update the immunizations of the most vulnerable Americans. Two years ago, when Covid shots were first introduced, the federal government sent teams into thousands of nursing homes and community centers to vaccinate seniors, curbing the devastation of the virus.But so far this fall, the White House has only offered grants to community organizations to get shots into the arms of older people, without the clear messaging strategy or logistical support that they need most, many caregivers and nursing home executives said in interviews.“The governmental and philanthropic support feels nonexistent,” said Debbie Toth, the chief executive of the nonprofit Choice in Aging, who helped bring thousands of the initial vaccines to adult care facilities and housing complexes in the East Bay of California in early 2021.The diminishing immunity of seniors has largely transformed the Covid pandemic in the United States from a threat against the unvaccinated to one against the old, many of whom were once well protected. People over 70 are being admitted to a hospital with Covid at a rate four times higher than that of the general population.According to the C.D.C., 95 percent of people 65 and older got their initial Covid vaccines, but only one-third have received the updated booster.Jamie Kelter Davis for The New York Times The most recent available death counts by age showed that almost 90 percent of Covid fatalities were among people over 65.“The evidence is clear: Even if you got the shot two years ago, your immunity has waned. But the people who most need to hear that have not,” said Dr. Michael Wasserman, a geriatrician and the public policy chair of the California Association of Long Term Care Medicine. “When you combine pandemic fatigue with no real plan from the government together, what we have is a perfect storm.”Read More on the Coronavirus PandemicBoosters: Americans who received updated shots for Covid-19 saw their risk of hospitalization reduced by roughly 50 percent this fall compared with certain groups inoculated with the original vaccines, the Centers for Disease Control and Prevention reported.Vaccine Mandates: After the ferocious battles over Covid shots of the past two years, simmering resistance to general school vaccine mandates has grown significantly.Free at-Home Tests: With cases on the rise, the Biden administration restarted a program that has provided hundreds of millions of tests through the Postal Service.Contagion: Like a zombie in a horror film, the coronavirus can persist in the bodies of infected patients well after death, even spreading to others, according to two startling studies.The Biden administration’s Covid plan for the winter includes $125 million in grants to two community organizations, USAging and The National Council on Aging, for programs to vaccinate older Americans — a far less direct approach than when it dispatched CVS and Walgreens workers into care centers after the first shots were authorized. The plan also includes letters to governors encouraging more nursing home shots and a television ad campaign that targets seniors in racial and ethnic minority groups.Mary Wall, the chief of staff of the White House Covid response team, said the administration was doing what it could with the limited resources available, but acknowledged that this time, the administration was relying on states to shoulder more of the burden.“We’re really instead asking them directly, please go and host on-site clinics,” she said.She called the grants “a great start,” but stressed that a more robust financial investment would require cooperation from Congress, which has repeatedly refused President Biden’s request for an additional $10 billion in health funding, a vast majority of it for the coronavirus response.“Realistically,” she said, “this is not something that we have gotten more money for, for a while, despite repeated asks to Congress. We’ve been trying really hard to look with great sobriety at our resources.”Bonnie Ronk, a participant at Choice in Aging, urged others to become vaccinated as the pandemic raged. But she has not received the bivalent Covid booster, saying she didn’t even know about it.Jim Wilson/The New York TimesEpidemiologists agree that among all pillars of a national response, widespread vaccination is among the most valuable. They estimate that Covid shots prevented 650,000 hospitalizations and 300,000 deaths among seniors and Medicare beneficiaries in 2021 alone.But the virus has since evolved, and the original vaccine formula is no longer a good match for circulating variants, a particular danger to seniors with weakened immune systems and underlying conditions like heart disease and diabetes.Even the bivalent shot has limited ability to prevent infections from the latest Omicron variants, but it is very effective at preventing serious illness and death. According to C.D.C. data, people 50 and older who received multiple boosters had half the risk of dying from the virus than those with just one booster.Dr. Sabine von Preyss-Friedman, a geriatric specialist and the chief medical officer of Avalon Health Care Group, said the apathy among some seniors reflected a misconception about the vaccine’s purpose.“People are thinking, ‘I got the shot, and I still got Covid, so what’s the point?’ They aren’t thinking about the fact that they got Covid and lived.”As part of the federal push, the Centers for Medicare and Medicaid Services also added a recording about the vaccine to its 1-800-MEDICARE line and sent emails to newsletter recipients “to share information on these updated vaccines, including when and how to get them.”But a recent survey by the Kaiser Family Foundation, a nonpartisan research organization, found that 40 percent of people 65 and older said they had heard little or nothing about the new booster. About half of homebound Americans 70 and older don’t have a computer, according to surveys, and more than half have not used email or the internet in the past month.Choice in Aging’s mascot encouraged masking. “Not all heroes wear capes,” a sign declared, “but they do wear masks.”Jim Wilson/The New York TimesContra Costa, the East Bay county where the Mt. Diablo Center operates, hasn’t experienced the politicization that has turned many American communities against public health measures. Here, front yards are still dotted with signs praising health workers. A 14-row parking lot has been repurposed for drive-through Covid testing.Posters in every walkway encourage six feet of distance. The center’s mascot is a stuffed pig in a rainbow cape wearing a miniature mask. “Not all heroes wear capes,” a sign declares, “but they do wear masks.”Yet even at this facility, where 100 percent of participants received their initial vaccines, only 40 percent have gotten the bivalent booster. At Pleasant Hill Post Acute, four miles south, every resident received the original shots, but only one in five is now up to date. At Vacaville Convalescent and Rehab, just north, almost 90 percent of residents were vaccinated, but 13 percent are up to date. Seven residents there tested positive for Covid last week.Ms. Ronk has a chronic inflammatory lung condition that puts her at risk of severe Covid. She said she liked to stay “as healthy as I can,” country music blaring as she exercised in the center, using plastic water bottles as dumbbells.She would have been “darn glad to get it,” Ms. Ronk said of the bivalent booster, had she known about it.Alexandr Makedonsky, 84, a former denture technician who considers himself “very pro-science,” said he eagerly sought the initial series of Covid vaccines and two boosters after a friend was hospitalized with the virus. He didn’t know the fifth shot was better suited to Omicron.Part of the problem, according to Alex Stoia, a nurse at the facility, is that the eligibility criteria for the new vaccine was not straightforward.“I can’t tell you the number of people who asked whether they should wait longer for the bivalent, since they’d just gotten a different booster in September, and we didn’t know what to tell them,” she said. “Even the people advising me couldn’t figure out the recommendations.”Ms. Toth, left, with Faina Gutkin, who hasn’t yet gotten the bivalent booster. “I feel fine,” she said. “Why do I need it?”Jim Wilson/The New York TimesLogistics are also a mammoth challenge. Ms. Stoia, who manages care for homebound seniors, said taking them to vaccination clinics can be nearly impossible: They may not hear the phone ringing; there’s nobody to help them get dressed; it’s too cold to wait on the curb for the van and, when it arrives, the electric wheelchair often doesn’t fit.In Los Angeles County, where an estimated 500,000 residents are homebound, the public health department said it sent only eight nurses to provide in-home vaccinations each day.“They need to understand that you can’t just tell people to get the vaccine, you have to bring the vaccine to the arm,” said Ms. Toth. “And trust me, that last mile is the hardest.”To many public health experts, the most difficult-to-teach seniors are those who doubt the new vaccine’s worth. New survey data from the Kaiser Family Foundation showed that about one-third of adults 65 and older who received the original series of Covid vaccines but not the booster said they didn’t think they needed it, and a similar share said that they didn’t think its benefits were worth it.Dr. Noah Marco, chief medical officer of the senior care nonprofit Los Angeles Jewish Health, said he “continues to be amazed” that the federal government has not enlisted marketing experts to “create updated messaging that actually works.”“Coca-Cola spent billions of dollars over decades convincing us that we need to be buying and drinking bubbly water with sugar and caramel in it. Come on, is there really nobody around to lend a hand here?” Dr. Marco said.At Mt. Diablo, the 51 seniors who still haven’t received the updated shot could use a fresh pitch. Two friends, Tsilya Tankover, 95, and Faina Gutkin, 77, got their initial vaccines, but they are among those refusing the booster that fights Omicron.“I feel fine,” Ms. Gutkin said, pushing around the collard greens on her plate as she shared plans to go tango dancing. “Why do I need it? I’m still waiting for someone to tell me that.”

Pregnant women are more likely to die of a drug overdose than the average woman of childbearing age, but less likely to be accepted for medication-based treatment.The Biden administration will use federal courts and health programs to expand the use of medication to treat substance abuse disorders in pregnant women, according to a report by the White House to be released Friday. The plan is part of the administration’s broader effort to combat a drug crisis that now kills more than 100,000 Americans annually.Under the new initiative, the Justice Department, the Department of Veterans Affairs and the Indian Health Service will be responsible for improving women’s access to medicines like buprenorphine and methadone. These treatments have been controversial, but are increasingly being embraced as a scientifically proven way to reduce dependency and save lives.Opioid use disorder among pregnant women has more than quadrupled in recent years, according to the Centers for Disease Control and Prevention, and is associated with low birth weight, preterm labor and miscarriage. Pregnant women are more likely to die of a drug overdose than the average woman of childbearing age, but less likely to be accepted for appointments with buprenorphine providers.“This is a bold statement, a big moment, coming from the president and the vice president, to show that pregnancy is the golden opportunity to help women get into recovery,” said Dr. Anna Lembke, the medical director of addiction medicine at Stanford, who was not involved in the plan’s design.But the administration’s blueprint is vague on funding, and some policy analysts worry that it falls short on the mechanisms and detail needed to push agencies and health institutions to move faster.Most items in the plan do not require additional appropriations from Congress. But officials asked for hundreds of millions of dollars more toward various child welfare initiatives in fiscal year 2023, including tripling mandatory funding to $60 million from $20 million for one program focused on families navigating substance abuse.Andrew Kessler, the founder of the behavioral health consultancy Slingshot Solutions, said that without sufficient funding from Congress, this initiative won’t amount to lasting change. He likened the administration’s “deeply researched” plan to the thick black outlines found in a coloring book.Fentanyl Overdoses: What to KnowCard 1 of 5Devastating losses.

BROKEN ARROW, Okla. — It was Lachlan Rutledge’s sixth birthday, but as he mustered a laborious breath and blew out one candle, it was his mother who made a wish: for a pediatric hospital bed in northeast Oklahoma.The kindergartner has a connective tissue disorder, severe allergies and asthma. Those conditions repeatedly landed him in the pediatric intensive care unit at Ascension St. John Medical Center in Tulsa, with collapsed veins and oxygen levels so low, he was unresponsive to his mother’s voice.But in April the hospital closed its children’s floor to make room for more adult beds. So on a September morning, after coming down with Covid for the fourth time and with what looked like bilateral pneumonia, Lachlan was struggling to breathe in an overcrowded emergency room at the Children’s Hospital at Saint Francis — the only remaining inpatient pediatric option in Tulsa.“We’re always preparing for battle. It’s just a question of where we’re going to fight,” said his mother, Aurora Rutledge, looking frightened as she twisted the blonde ringlets that poked out from under Lachlan’s Spider-Man headphones. Hospitals around the country, from regional medical centers to smaller local facilities are closing down pediatric units. The reason is stark economics: Institutions make more money from adult patients.In April, Henrico Doctors’ Hospital in Richmond, Va., ended its pediatric inpatient services. In July, Tufts Children’s Hospital in Boston followed suit. Shriners Children’s New England said it will close its inpatient unit by the end of the year. Pediatric units in Colorado Springs, Raleigh, N.C., and Doylestown, Pa., have closed as well.“They’re asking: Should we take care of kids we don’t make any money off of, or use the bed for an adult who needs a bunch of expensive tests?” said Dr. Daniel Rauch, chief of pediatric hospital medicine for Tufts Medicine, who headed its general pediatric unit until it closed over the summer. “If you’re a hospital, that’s a no-brainer.”Lachlan’s backpack is full of EpiPens and medications — and clear labeling — to manage his allergies when he’s at school.Melissa Lukenbaugh for The New York TimesMany hospitals have converted children’s beds to adult I.C.U. beds during the pandemic and are reluctant to change them back. Now, staff shortages, inflation — drug costs have increased 37 percent per patient compared to prepandemic levels — low Medicaid reimbursement and dwindling federal subsidies granted during the pandemic have left some health centers operating on negative margins and eager to prioritize the most profitable patients. Young patients like Lachlan, who has private insurance, occupy beds to recover from infections or asthma attacks but don’t undergo lucrative, billable procedures — like joint or heart surgeries — that are more common among aging patients.Physician reimbursement through Medicaid, the insurance program for low-income people, is often only about 70 percent of the amount reimbursed through Medicare, the insurance program for elderly people of all incomes. More than a third of children in the United States are enrolled in Medicaid.There have been no aggressive legislative efforts to keep hospitals from closing or shrinking their pediatric units. Democratic senators introduced a bill last year to grant funding to specialized children’s hospitals to improve their infrastructure, but it has not moved past the assigned committee.Health policy experts say an important solution would be to encourage hospitals to care for children by increasing Medicaid reimbursement rates. But even higher Medicaid and private rates wouldn’t come close to what hospitals can charge for remunerative adult procedures, and with many state budgets already strained, experts say the regulatory move is unrealistic.Hospitals that no longer admit children rely on transferring them to pediatric units at other hospitals. But when even the largest pediatric floors in the country are at capacity, the pileup of critically ill children in E.R.s can cause patients’ conditions to worsen.An E.R. crushLachlan during a recent visit to the overcrowded emergency room at The Children’s Hospital at Saint Francis — the only remaining inpatient pediatric option in Tulsa.Emily Baumgaertner/The New York Times“Picu kids don’t belong here,” an overwhelmed E.R. doctor in a small Boston area hospital wrote two weeks ago to his hospital’s chief medical officer in an expletive-ridden text message reviewed by The Times. (P.I.C.U. is the acronym for pediatric I.C.U. The text message was shared on the condition that the hospital not be identified.)Every I.C.U. for children in Boston was full at the time, and the nearest open beds were in New Haven, Conn., and Vermont. The doctor who sent the text message considered intubating the child in the E.R. while he waited for a closer bed to become available.As children return to school, waves of illnesses are overrunning many of the units that remain.“Forget the two-week January crush. We couldn’t find beds in May or August or September,” said Dr. Melissa Mauro-Small, the chief of pediatrics at Signature Healthcare Brockton Hospital, near Boston. “There is no more respiratory season. It’s respiratory season year-round.”A hospital in Plymouth, Mass., that had not transferred a patient to Dr. Mauro-Small’s hospital in a decade did so six times in 10 days recently, she said. The E.R. staff at Lowell General Hospital outside Boston had to ask eight hospitals across New England whether they had room for an intubated 2-year-old, according to patient charts reviewed by The Times. It transferred another patient to the closest I.C.U. bed available — in Maine.“At some point, this was going to become a crisis,” Dr. Mauro-Small said. “And here we are.”St. John Medical Center in Tulsa had been a community treasure for almost a century when Ascension acquired it in 2013. The closure of the pediatric unit triggered opposition from both families and referring pediatricians.Dr. Michael Stratton, a pediatrician in Muskogee, Okla., said Ascension St. John had been “the number one place to send a child,” and its pediatric unit closure had been “such a huge disservice to all of eastern Oklahoma.”Lachlan’s morning routine involves time with the inhaler after breakfast while preparing for school.Melissa Lukenbaugh for The New York TimesA spokeswoman for Ascension St. John, where Lachlan had been admitted to the I.C.U. three times before the closure, declined to be interviewed but said in an email that the closure was driven by a demand for more adult beds. She also pointed to past statements that said the Children’s Hospital at Saint Francis was “more than capable of picking up the slack.”A spokeswoman for the Children’s Hospital at Saint Francis said that it had occasionally reached full capacity and that the staff transferred about 23 patients to other facilities, including in Arkansas, so far this year.The E.R. “was busy even prior to the closure of the St. John’s pediatric unit,” she said. Still, she said the hospital had not become overburdened. “Volume is fairly consistent with what we usually see on a seasonal basis,” she said.Some Oklahoman families with chronically ill children say they routinely drive to Memphis, St. Louis and Rochester, Minn., for care. The distances cause financial strain and, in the worst cases, cause them to forgo care, said Katy Kozhimannil, director of the University of Minnesota Rural Health Research Center.For those in rural communities, pediatric closures have made travel to what Dr. Rauch calls “bread-and-butter pediatrics” untenable. Sixteen-year-old Johnny in Childress, Texas, had to be home-schooled so he could travel eight hours to Dallas for dialysis treatment three times a week, according to his doctor.Jamaal Bets His Medicine, a 2-year-old with an autoimmune disease in Fort Kipp, Mont., routinely takes an 11-hour trip to Billings, Mont., to receive infusions, his mother, Patricia, said.‘Children are not small adults’Lachlan and his mother, Aurora Rutledge, outside the Saint Francis Emergency Center.Melissa Lukenbaugh for The New York TimesThe decline of local access to children’s inpatient care began over a decade ago and accelerated during the pandemic. Between 2008 and 2018 — the most recent national data available — pediatric inpatient units in the United States decreased almost 20 percent, and nearly a quarter of children found themselves farther from their nearest pediatric unit.The steepest decline in pediatric inpatient beds was in rural regions, where large health systems acquired community hospitals and consolidated pediatrics to one campus. Centering pediatric care in specialized centers can erode a local hospital’s ability to care for a critically ill child, doctors say.“Children are not small adults,” said Dr. Meredith Volle, a pediatrician at Southern Illinois University School of Medicine in Springfield, Ill., who routinely sees patients who travel from two to three hours away. The number of pediatric beds in Illinois has declined, and 48 of its counties now have no pediatrician at all.“When nurses and respiratory therapists become less comfortable with children’s cases, when the units don’t have child-sized equipment,” Dr. Volle said, “at a certain point, you really shouldn’t treat kids anymore because you don’t treat them often enough to be good at it.”Critically ill children are four times as likely to die in hospitals and twice as likely to die in trauma centers that scored low on a “pediatric readiness” test, according to research. Only one-third of children in a national research survey had access to an emergency department deemed highly “pediatric-ready,” and of those, nine out of 10 lived closer to a less-prepared one.A parent who is unaware of the wide variability, said Dr. Katherine Remick, the executive director of the National Pediatric Readiness Quality Initiative, “could make a split-second decision that changes their child’s fate.”Lachlan’s life“We’re always preparing for battle. It’s just a question of where we’re going to fight,” said Ms. Rutledge.Melissa Lukenbaugh for The New York TimesThe Rutledge family lives in Broken Arrow, a sunny Tulsa suburb with a frozen custard shop and a dentistry called Super Smiles. Their front porch is home to potted succulents, an abandoned scooter and a 140-pound Great Dane named Thor.But their lives are far from ordinary. The last time Lachlan needed to see an allergy specialist, his mother packed the car with his nebulizer and medications for a 14-hour drive to Denver, leaving her husband, their two other sons and her mother, who was undergoing chemotherapy, for two weeks. Later, when doctors told her that Lachlan’s disorder appeared to be causing stomach ulcers — but that the sole pediatric gastroenterologist at Saint Francis wasn’t available for months — she began planning a journey to Dallas.On the September morning that Lachlan was in St. Francis struggling to breathe, the E.R. was so busy that Ms. Rutledge hooked him up to a pulse oximeter herself, quieting the monitor’s settings so it wouldn’t frighten him every time his heart rate spiked.Lachlan tugged at his collar bone, his chest looking retracted. Five hours later, he still hadn’t been admitted. Ms. Rutledge’s hands trembled and tears streamed down her face.“I know you guys are exhausted at this hospital, and I get it,” she shouted, leaning over Lachlan’s bed to level her eyes with the attending physician on the other side. “But you will not send this child home so he can watch his own vitals drop.”Lachlan was discharged from the E.R. after 10 hours with a course of steroids to fight the inflammation in his lungs. He sleeps in his parents’ bedroom so they can check his oxygen levels and administer nebulizer treatments every few hours throughout the night.

The guidance comes as Americans are coping with illness, isolation and loss from the pandemic, as well as other stressors like inflation and rising crime.A panel of medical experts on Tuesday recommended for the first time that doctors screen all adult patients under 65 for anxiety, guidance that highlights the extraordinary stress levels that have plagued the United States since the start of the pandemic.The advisory group, called the U.S. Preventive Services Task Force, said the guidance was intended to help prevent mental health disorders from going undetected and untreated for years or even decades. It made a similar recommendation for children and teenagers earlier this year. The panel, appointed by an arm of the federal Department of Health and Human Services, has been preparing the guidance since before the pandemic. The recommendations come at a time of “critical need,” said Lori Pbert, a clinical psychologist and professor at the University of Massachusetts Chan Medical School, who serves on the task force. Americans have been reporting outsize anxiety levels in response to a confluence of stressors, including inflation and crime rates, fear of illness and loss of loved ones from Covid-19. “It’s a crisis in this country,” Dr. Pbert said. “Our only hope is that our recommendations throw a spotlight on the need to create greater access to mental health care — and urgently.”From August 2020 to February 2021, the percentage of adults with recent symptoms of an anxiety or a depressive disorder increased to 41.5 percent from 36.4 percent, according to one study cited by the task force. The guidance was issued in draft form. The panel will finalize it in the coming months after reviewing public comments. While the panel’s recommendations are not compulsory, they heavily influence the standard of care among primary care physicians across the country.In response to the recommendations, mental health care providers emphasized that screening programs are useful only if they lead patients to effective solutions. At a time when the country is “short on mental health resources on all levels — psychiatrists, psychologists, and therapists — that’s a real concern,” said Dr. Jeffrey Staab, a psychiatrist and chair of the department of psychiatry and psychology at Mayo Clinic in Rochester, Minn.“We can screen lots of people, but if that’s all that happens, it’s a waste of time,” said Dr. Staab, who is not on the task force.Psychiatrists, while pleased with the attention on mental health, also underscored that a standardized screening is only the first step toward a diagnosis, and that providers will need to guard against assuming that a positive screening result indicates a clinical disorder.For many Americans, the screening could simply reveal a temporary period of distress and a need for extra support. “When providers say, ‘You must have a disorder, here, take this,’ we could face an overprescribing problem,” Dr. Staab said. “But the opposite scenario is that we have lots of people suffering who shouldn’t be. Both outcomes are possible.”Rising mental health issues are not unique to the United States. Anxiety and depression increased by 25 percent globally during the first year of the pandemic, according to the World Health Organization, and has only partially improved since. About a quarter of men and about 40 percent of women in the United States face an anxiety disorder in their lifetimes, according to the task force, though much of the data is outdated. Women have nearly double the risk of depression compared with men, studies show, and the recommendation paid special attention to screenings for pregnant and postpartum patients. Physicians typically use questionnaires and scales to survey for mental health disorders. According to the recommendations, positive screening results would lead to additional assessments at the provider’s discretion, depending on underlying health conditions and other life events.Some primary care physicians expressed concern that adding an additional responsibility to their wide-ranging checklist for brief patient appointments is implausible.Dr. Pbert of the task force said that those providers should “do what they already do on a daily basis: Juggle and prioritize.”She also said the task force’s rigorous review of available studies revealed that people of color are often underrepresented in mental health research, which, if not addressed, could contribute to a cycle of inequity.Mental health disparities are rampant in the United States, where Black patients are less likely to be treated for mental health conditions than are white patients, and Black and Hispanic patients are both more frequently misdiagnosed. From 2014 to 2019, the suicide rate among Black Americans increased by 30 percent, data shows.Standardizing screening for all patients could help combat the effects of racism, implicit bias and other systemic issues in the medical field, Dr. Pbert said.The task force panel did not extend its screening recommendations to patients 65 and older. It said there was no clear evidence regarding the effectiveness of screening tools in older adults because anxiety symptoms are similar to normal signs of aging, such as fatigue and generalized pain. The panel also said it lacked evidence on whether depression screening among adults who do not show clear signs of the disorder would ultimately prevent suicides.The task force will accept public comments on the draft recommendation through Oct. 17.