Newsletter

But ABLE is more flexible than the college savings vehicle. For instance, ABLE money can be linked to a cash management account, with check writing and a Fidelity-issued debit card, and then used to pay qualified expenses at any time.

Editor’s Note: While this is a great option for many families, there are also other options such as special needs trusts and PASS accounts that may be better suited to individual needs. We advise that families discuss all of their options with a financial planner or attorney with experience in these issues.

What Do I Do If an ICE Agent Comes Looking for a Patient or Patient Information?

Most of the time ICE agents are supposed to avoid sensitive locations such as hospitals and doctors’ offices (also schools, places of worship, weddings and funerals, and public demonstrations). ICE agents can enter these places if they get a supervisor’s approval, or in situations related to national security, terrorism, or public safety, or where there is an imminent risk of destruction of evidence in an ongoing criminal case. The Trump Administration has said that the so-called “sensitive locations” memo that lays out these expectations is still in effect.

On March 1, 2017 the Social Security Administration (SSA) announced that it would reopen its decisions to deny spousal or survivor’s benefits to individuals who had been married to someone of the same sex, and whose marriage wasn’t recognized because of a discriminatory state or federal ban on marriage.

This ruling and policy applies not only to individuals who were denied benefits after the Supreme Court struck down federal discrimination against same-sex spouses (in United States v. Windsor in 2013) and state discrimination (in Obergefell v. Hodges in 2015), but also to individuals who applied for and did not receive benefits BEFORE these Supreme Court decisions because of the discriminatory laws in effect at the time they applied.

A new Fact Sheet on this guidance from Justice in Aging includes more detailed information about who is affected by the new guidance, who isn’t, and what advocates and their clients should do to get their cases reopened.

This fact sheet was authored in collaboration with our partners at SAGE, Lambda Legal, and the National Committee to Preserve Social Security and Medicare.

This policy change applies to applications for spousal or survivors benefits that SSA denied prior to the Windsor and Obergefell decisions because it did not recognize their marriages. Even those who began receiving SSA benefits following the Supreme Court decisions may be due retroactive benefits for the period between when they first applied (and were denied) and when SSA finally recognized their marriage.

This MAY apply to some individuals who did not actually submit applications for spousal or survivors benefits with SSA prior to the Windsor and Obergefell decisions (because they believed filing those applications would have been futile), if they can prove they contacted SSA about filing an application and SSA staff discouraged them from doing so (based on SSA’s discriminatory policies regarding their marriage). If so, they MAY be able to establish what’s called a “protective filing date” for their application and should consult the office where they filed the application to establish that date.4 Even those who can prove they applied for a reduced retirement benefit based on their own work record because SSA discouraged them from applying for spousal benefits, may be able to seek the higher spousal benefits.5

SSA has identified approximately 800 individuals whose applications for benefits it denied because the agency did not recognize their marriages to a same-sex spouse.

SSA says it will reach out to those individuals to let them know those denied applications will be reopened, but it is not clear when SSA will make that contact, and if they have current contact information for these individuals.

Individuals do not need to wait for SSA to contact them to request that these applications be reopened.

There may be others whose denials SSA has not identified in its systems. SSA will not contact them. They will need to contact SSA directly to request that their denied applications be reopened.

SSA will go as far back in time as it must to pay all benefits that it denied by applying these now-invalidated laws.

-From New Guidance on Spousal & Survival Benefits for Married LGBT Individuals, Justice in Aging, April 18, 2017 and the Factsheet.

The MA Department of Transitional Assistance recently announced that starting June 5th, 2017, Transitional Assistance Offices (TAOs) will have standardized business hours. They’ll be open for business from 8 AM to 5 PM (Monday through Friday).

The DTA Assistance Line IVR (automated case information), and DTA Connect can still be accessed 24/7.

This information has been updated on the DTA’s website. DTA staff have been notified and there will be communication sent to clients. “Any assistance you can provide with getting this information out to our mutual clients is greatly appreciated” said Lorraine Akinyi Ward, Acting Director for SNAP Outreach in an e-mailed statement

-Adapted from SNAP Application Assistance "Next Steps" Flier; DTA Update re Standardized Local DTA office hours, FoodSNAPCoalition listerv, on behalf of Patricia Baker, Mass Law Reform Institute, May 03, 2017.

SNAP outreach partners frequently get questions about "what happens after I file an application for SNAP?" Attached is a revised document prepared by MLRI and Project Bread to give to households that you are helping with SNAP Applications. This describes the "Next Steps" they should expect after filing a SNAP application, including:

As part of last year’s revision of nursing facility regulations, CMS prohibited federally-certified nursing facilities from obtaining arbitration agreements at the time of admission. CMS concluded that it was unfair to have residents and families waive legal rights during such a difficult and chaotic time. Now, however, CMS has reversed course and has filed language that would revise the regulation to allow facilities to obtain arbitration agreements at admission. For more on the revised regulations, see the series of issue briefs developed by Justice in Aging in partnership with the Center for Medicare Advocacy and the National Consumer Voice for Quality Long Term Care.

Revised federal nursing facility regulations have increased protections for nursing facility residents.

These issue briefs are the 9th and 10th in a series on the new regulations. All of the briefs were created jointly by Justice in Aging, the National Consumer Voice for Quality Long-Term Care, and the Center for Medicare Advocacy.

- From Two New Issue Briefs on Revised Nursing Facility Regulations, Justice in Aging, May 03, 2017.

Every Thursday evening, in the lobby of a city-owned building on Court Street, a team of counselors sits ready to help tackle one of Boston’s thorniest challenges. One tenant at a time.

It’s a weekly clinic for at-risk renters, part of a push by the Walsh administration to combat displacement. The clinics are run by the city’s new Office of Housing Stability, which Mayor Martin J. Walsh created last year to try to help the hundreds, perhaps thousands, of Bostonians pushed out of their homes each year by disasters, rent increases, and their landlords’ redevelopment plans.

To Lydia Edwards, a former legal aid attorney who launched the effort, the clinics highlight the many hazards renters can face in one of the nation’s priciest housing markets. Not just rent hikes but broader troubles — a fire, job loss, domestic abuse — can put tenants at risk of losing their homes. “People enter a housing crisis for all sorts of reasons,” she says. “Our office is doing our best to come up with systems to help them.”

While the clinics are the hands-on leading edge, the Office of Housing Stability has big-picture policy goals, too. Edwards and her team lobby city and state lawmakers to strengthen tenant protection laws, including one that would allow the city to track eviction activity as it happens. At the same time, they’re talking with landlords, building relationships, and encouraging policies they hope will head off evictions.

A new website can help Cambridge families find local activities, services, and resources you are looking for in Cambridge.

Questions? Contact Find It Cambridge manager, Hector Acevedo by email info@finditcambridge.org or phone 617-349-6392.

According to the Massachusetts Department of Public Health, Cape Cod’s only 24/7 emergency domestic violence shelter lost state funding last month because of concerns about client safety and ongoing staffing problems, forcing it to shut down by the end of June.

The state had previously limited admissions to the shelter after more than a year of “notices of unsafe and non-compliant shelter conditions by the contract manager,” according to the department’s review- obtained by the Cape Cod Times through a public records request of Cape Cod Shelter and Domestic Violence Services’ funding application.

Shelter clients, who spoke to the Times and requested anonymity to protect them from their abusers, say they’re not being urged to leave well ahead of the facility’s planned June 30 shutdown date and have raised their own concerns about safety and staffing there since the announcement in late April that the shelter would close.

No counseling services or help is being offered in the midst of the turmoil over loss of funding, said a client.

The problems are not new, according to a former shelter worker, who asked not to be identified because of fear of retribution within the community.

As of earlier this month, High Point Treatment Center- CASTLE’s detox/stabilization services no longer serves young teens with substance use disorder. Previously there were 2 programs in Mass. serving youth ages 13-17, but now only Worcester-based Community Healthlink MYR will serve ages 13-17; High Point only will serve ages 16-20.

Community Healthlink
Motivating Youth Recovery (MYR) Youth Detoxification & Stabilization
Population: ages 13-17
Worcester, MA
Phone: 508-860-1244

High Point Treatment Center – CASTLE
CASTLE Youth Detoxification & Stabilization
Population: ages 16-20
Brockton, MA
Phone: 508-638-6000

The Institute for Health and Recovery, Youth Central Intake and Care Coordination ( 1-866-705-2807) will continue to support families, state agencies, and other key stakeholders to identify resources and the most appropriate course of action for youth ages 13-17, in need of treatment for substance use.

Many immigrant rights and community groups are offering “Know Your Rights” (KYR) trainings for immigrants concerned about the current climate of stepped up enforcement efforts.

The newly formed Lynn Rapid Response Network will be hosting a comprehensive legal clinic on Saturday, June 3 from 10am-2pm. This clinic will provide a KYR presentation in 7 languages followed by free legal consults with immigration lawyers, consults with social workers for assistance in filling out family safety paperwork, a resource fair including presence of the AG's office and several consulates (currently Mexico and Guatemala, possibly El Salvador) to answer questions regarding country-specific immigration and document processing. It will also offer food, a DJ, kids activities and a relaxation station with aromatherapy and possibly massage chairs!

Here's a flyer in 6 languages (English, Spanish, Haitian-Creole, Arabic, Khmer and Russian). Feel free to invite anyone who could use this clinic.

-From Lynn hosting comprehensive legal clinic; call for volunteers! Greater Boston Health & Law Immigrant Solidarity Network, on behalf of Ginger Leigh, May 24, 2017.

Cristal is a 2-year-old girl born with spina bifida, a condition that has required multiple surgeries and left her with limited sensation in her lower extremities.

Over the past month, she has endured long, uncomfortable commutes between the Lowell homeless shelter where the state is housing her family and frequent appointments with her medical providers in Boston, according to recent court filings. With traffic, the drive can take two hours each way, putting her at risk of pressure sores. It’s a situation one of her doctors calls “intolerable.”

Her mother, Jocelin Gruilart, is asking a judge to direct the state to move the family from the shelter to “an appropriate setting in the Boston area, including a hotel room if no other space is available,” according to an emergency motion in Suffolk Superior Court.

But the administration of Republican Governor Charlie Baker, who won election in 2014 pledging to end the practice of sending homeless families to hotels and motels at state expense, is fighting the motion. A state lawyer says agreeing to the request “could open the floodgates to who-knows-what down the road.” Instead, the government notes that the family’s current accommodations in Lowell are handicap accessible, and it intends to move them to the Boston area when possible.

The case illustrates the human dimension of one of thorniest entitlement program debates facing Massachusetts as Baker works to reduce the number of homeless families in motels at state expense to zero. There were 1,500 families in such accommodations when he took office in January 2015, but just 55 on Monday night.

On one hand, advocates and lawmakers of both parties agree that motels are often a poor option for housing families, separating them from the social support of relatives and friends, a clean place for children to play, and a kitchen.

On the other, advocates say a temporary stay in a motel may be precisely what’s needed for certain families with unusual requirements — such as Cristal and her parents.

Philip Mangano, a longtime advocate for the homeless who worked for the administrations of George W. Bush and Barack Obama, and who has repeatedly lauded the Baker administration for its efforts to reduce the number of families in motels, bemoaned the state not placing Cristal closer to her doctors.

Mangano, who is based in Boston, has spent decades decrying “ideologues” who press homeless families into “welfare motels” where they remain mired, sometimes for years.

Recent state data show families in state shelters have stayed an average of 297 days, but families in a state-funded motel have stayed an average of 536 days.

But after reading court filings about Cristal, he said common sense and humanity must sometimes override valid policy constructs.

More than 90,000 Boston residents who are enrolled in the state's Medicaid program do not receive public assistance to pay for food, city officials said this month as they urged support for a bill that would create a common application program for MassHealth and other public benefit programs.

Under the bill, filed by Sen. Sal DiDomenico, people applying for or renewing their MassHealth coverage would be provided with an "opportunity to initiate a common application" for MassHealth and for programs administered by the Department of Transitional Assistance, including the federal Supplemental Nutrition Assistance Program (SNAP).

The bill (S 612) also directs state officials to develop a common portal for individuals to simultaneously apply for MassHealth coverage, SNAP, welfare, veterans benefits, child care and housing subsidies, fuel assistance and other needs-based benefits.

Clare Gordon of the League of Women Voters of Massachusetts told the Joint Committee on Health Care Financing that no one program meets all the needs of someone who suddenly loses most of their income, and the process of applying for several programs can pose challenges.

"The poorer one is, the harder it is to go around to all of the places that may give you help," she said. "Often you don't have a car, no dependable childcare, and no cash to get copies of documents."

A former social worker, Gordon said she "saw countless individuals get more desperate" as they sought various types of assistance, and that a common application would streamline the work of state agencies serving people entitled to benefits.

Boston Public Health Commission executive director Monica Valdes Lupi said the issue is one of health equity. The Boston population that has MassHealth but not SNAP (the “SNAP Gap”) is primarily concentrated in four neighborhoods -- Mattapan, Roxbury, East Boston and Dorchester -- that also have a high percentage of residents who say they lack money to buy food.

DiDomenico, an Everett Democrat, said his bill would "help low-income residents meet their basic needs." He said many MassHealth recipients who could receive SNAP miss out on the federally funded benefits because they are unaware that they are eligible.

-Excerpted from COMMON APP SOUGHT FOR PUBLIC BENEFIT APPLICANTS, State House News Service, May 2, 2017 (Paywall); forwarded by Patricia Baker, Mass Law Reform Institute.

Pregnant women would be offered more protections in the workplace under a bill that has won unanimous approval in the Massachusetts House of Representatives.

The legislation would require employers to offer "reasonable accommodations" for pregnant or nursing workers. Such accommodations could include modified work schedules, temporary transfers to less strenuous positions or things as simple as a stool to sit on and more frequent bathroom breaks, provided they don’t cause a business “significant difficulty or expense.”

The federal Pregnancy Discrimination Act prevents employers from firing women for being pregnant but offers no additional protections, said Liz Friedman, lead organizer for the statewide coalition pushing the bill. The Americans with Disability Act covers some temporary conditions brought on by pregnancy, such as gestational diabetes, she noted, but doesn’t apply to more ordinary concerns, such as not lifting heavy loads.

“These minor accommodations aren’t covered under the ADA, nor should they be, because it’s not a disability, it’s a pregnancy,” Friedman said.

Backers say that while most business owners in the state act responsibly, there have been stories in Massachusetts of pregnant women being harassed or retaliated against, or forced to do manual labor that could jeopardize their health, or their unborn children.

Supporters say 18 other states provide similar protections for pregnant workers.

State Rep. Paul Heroux contends disabled parents are sometimes discriminated against when it comes to child custody rights and he wants to do something about it.

He said sometimes the judges consciously or even subconsciously assume disabled parents cannot care adequately for children by themselves.

Heroux, D-Attleboro, has filed a bill that prohibits disabilities from being used as a “negative factor” in determining awarding custody and visitation rights.

In cases where custody is denied, the bill would require judges to give a written reasons of how custody would have harmed the children.

Kate Nemens of state Mental Health Legal Advisory Commission, said discrimination is already illegal, but Massachusetts law does not specifically address discrimination against the disabled in custody cases.

Under the bill, she said, a judge could still deny custody if he or she thought it would endanger the children, but the judge would have to explain the “nexus” between the disability and the potential harm.

Nemens also said the judge would have to consider whether special equipment could overcome the potential problems.

As an example, she said a blind parent could be provided with a talking thermometer to take a child’s temperature, or a deaf parent could get flashing smoke alarms.

She said she does not know of any opposition to the bill, but it will only pass if legislators become more aware of the problem and make it a priority.

Dolores Rush of Quincy wishes she never obtained a reverse mortgage on her three-bedroom family home. She and her now-deceased husband had paid off their conventional mortgage and had no debts.

But she said a financial adviser persuaded the retired couple in 2009 to take out a $250,000 loan against the value of their home and funnel the money into investments — without explaining the financial repercussions, including $17,000 in closing costs alone. When monthly statements revealed that the Rushes were sinking further into debt, she called the state attorney general’s office for help.

“It’s like borrowing from Peter to pay Paul,’’ said the sprightly 74-year-old. “There are so many things they don’t tell you.”

Rush’s complaint spurred a state investigation into alleged collusion between a Massachusetts mortgage broker and an insurance agent and serves as a warning, state regulators say, about the perils of obtaining a complicated reverse mortgage.

Attorney General Maura Healey said last week that she had obtained a $137,500 settlement with the two men — James Moniz and Daniel Matthews — to discharge claims they colluded to profit from “risky financial transactions” that involved funneling reverse mortgage proceeds into other investments.

Reverse mortgages are meant to help people 62 and older “age in place” by giving them cash from the equity in their homes. Borrowers typically receive a loan or a line of credit, in a lump sum or in monthly payments. They are allowed to defer payments on the debt until they die, move away, or fail to pay taxes and insurance. Proceeds from the sale of the property can be used to pay off the loan.

Healey said people should be wary about using funds from the home loans to buy financial products like annuities, which provide investors with steady dividends over time. First, the costs of the reverse mortgage can more than offset the income from the annuity. Also, annuities pose other risks because there can be steep financial penalties for withdrawing funds ahead of time, according to the state’s lawsuit.

Moniz and Matthews admitted no wrongdoing. But there’s been a growing momentum among some financial advisers to market reverse mortgages to people with more financial means as part of an overall retirement strategy.

But the growth of reverse mortgages has been marred by deceptive practices, scams, and foreclosures. In December, the Consumer Financial Protection Bureau took action against three companies for deceptive advertising, claiming the groups falsely said homeowners could not lose their properties while they have reverse mortgages. Lenders can foreclose if owners don’t pay their property charges or maintain their properties.

To better educate homeowners, the industry organization, the National Reverse Mortgage Lenders Association, published an online guide in November. Among the recommendations, the pamphlet says, “It is never recommended that reverse mortgage borrowers use their loan proceeds to speculate on real estate or securities.”

Widespread addiction to opioids is causing record levels of overdose deaths in Massachusetts, but insurance companies and business advocates are balking at a bill that would make them pay for more than double the current mandated length of stay in addiction treatment.

State Sen. Karen Spilka and state Rep. Thomas Golden Jr. have filed bills in both branches of the state legislature mandating that insurers pay for up to 30 days of inpatient substance abuse treatment "as medically necessary," up from the current 14 days.

“We recognize the impact opioid addiction is having on Massachusetts families and are committed to ensuring that all residents of the Commonwealth who need treatment are able to get the care they need,” said the letter. “However, Senate Bill 1103 and House Bill 2394 take the approach that more days of inpatient services should improve the effectiveness of treatment when, in fact, it will impede access to services for patients and lead to higher costs for employers.”

Both bills would expand the number of days for acute treatment services and so-called clinical stabilization services, the treatment that comes after detox. The Senate bill would also mandate 30 days of coverage for “transition support services.”

Insurers and business advocacy groups also objected to legislation in 2014 mandating that insurers pay for up to 14 days of inpatient substance abuse treatment. The groups said at the time there was no clinical support for the current 14-day coverage requirement, calling the change “arbitrary and inconsistent with established clinical criteria.”

The Division of Insurance is in the process of evaluating the 14-day mandate, but the groups said preliminary health care data shows that patients are staying in beds longer and are being admitted more frequently, decreasing the number of new patients able to access services.

The business and insurance groups say they want more study on what the 14-day mandate has done before a 30-day mandate is put into effect. They also pointed to Pennsylvania, which put a 30-day coverage requirement in place in 1989, arguing that despite that mandate, it has the same rate of illicit drug abuse and overdose deaths as Massachusetts. They say that Pennsylvania’s costs to care for those with substance abuse problems more than tripled from 2009 to 2014.

The letter also contends that the mandate would only apply to smaller business and individuals purchasing plans on the connector, leaving out 57 percent of the private insurance market.

When you pore over all of Trump’s spending plans and revenue projections, a few elements really stand out.

Trump’s budget is held together by the largely groundless assumption that US economic growth will reach 3 percent over the next decade. That’s a fantastically high rate, well above the 1.9 percent rate assumed by the Congressional Budget Office.

Faster growth would mean rising incomes — and fattened government coffers. So with this one assumption, Trump mightily increases the amount of assumed tax revenue he can use to pay for programs or pare down the deficit, to the tune of $2.7 trillion over 10 years.

Also in Trump’s budget proposal are the tax cuts he outlined in a one-page summary document last month, including substantial reductions in both corporate and individual income tax rates.

These cuts are extremely expensive, costing more money than would be required for tuition-free college, universal preschool, and nationwide lead remediation combined. And while Trump’s team has championed those cuts as a boon for the middle class, the bulk of benefits would actually go to the nations’s highest earners.

Trump is proposing well over a trillion dollars in cuts to key strands of the social safety net. That includes reduced spending on food stamps, along with disability insurance, the children’s health insurance program (CHIP), and cuts to Medicaid that reach beyond the already substantial reductions in the Obamacare repeal bill. “The budget would cut Medicaid by up to $1.3 trillion over 10 years, layering additional cuts on top of the AHCA's already-drastic cuts of over $800 billion. This amounts to slashing Medicaid nearly in half over the next decade, and would leave millions of low-income older adults without the health care services they desperately need” said Kevin Prindiville, Executive Director of Justice in Aging in an e-mailed statement. According to Prindeville, the “budget would also slash Social Security by over $72 billion, reducing benefits provided through Social Security Disability Insurance (SSDI) and cutting billions from the Supplemental Security Income (SSI) program. These cuts would force low-income seniors and people with disabilities who depend on SSDI and SSI to pay for housing, food, and other essentials to live even further below the poverty line, threatening their very survival.

“Contrary to many reports that older adults are spared by this budget, this budget includes historic cuts to anti-poverty programs that provide an array of vital services to older adults including the Legal Services Corporation, State Health Insurance Assistance Program (SHIPS), the Supplemental Nutrition Assistance Program (SNAP), the Centers for Disease Control’s Fall Prevention Program, Senior Corps, the Low Income Home Energy Assistance Program (LIHEAP), Social Service Block Grants, Community Service Block Grants, and Community Development Block Grants.”

The governing idea behind these cuts is to encourage able-bodied Americans to seek work, instead of government handouts — part of a longstanding conservative effort to reduce dependence and increase self-reliance. But the inclusion of CHIP points to the limit of this approach. Roughly 60 percent of all Americans living in poverty are kids, seniors, students, or people with disabilities.

One potential boon for working families is a proposal for paid family leave spearheaded by Trump’s daughter Ivanka. Though even here, there is a potential trade-off, with the necessary money likely drawn from a pool currently dedicated to unemployment insurance.

The Department of Defense counts among the few clear beneficiaries in Trump’s budget, garnering an additional $54 billion in 2018. Homeland Security, too, would see a funding increase, as would Veterans Affairs.

Some government agencies, however, would face drastic funding reductions. That includes a 29 percent cut at the State Department, 31 percent at the Environmental Protection Agency, and 18 percent for the National Institutes of Health. Looking across the budget as a whole, cuts like these could have massive implications for scientific research, job training, even iconic programs like Habitat for Humanity and Teach for America.

There is basically zero chance that Trump’s budget will be embraced by Congress and turned into an actual spending plan. Several Republicans have already distanced themselves from the document, and even if they hadn’t, any specific appropriations bill would need to overcome a Democratic filibuster.

But don’t take that to mean Trump’s plans are irrelevant. Not at all. It’s just that they are likely to be enacted in other ways — outside the traditional budget process.

Right now, the two efforts with the greatest chance of generating real, conservative change are the push to replace Obamacare and the quest for far-reaching tax reform. That’s the more likely path for enacting some of the key tax and entitlement changes envisioned in Trump’s budget proposal.

-See the full Boston Globe article. Additional material from Justice in Aging's Statement on the 2018 Budget e-mail, Justice in Aging, May 23, 2017.

The ability to protect the health of mothers and babies in childbirth is a basic measure of a society's development. Yet every year in the U.S., 700 to 900 women die from pregnancy or childbirth-related causes, and some 65,000 nearly die — by many measures, the worst record in the developed world.

American women are more than three times as likely as Canadian women to die in the maternal period (defined by the Centers for Disease Control as the start of pregnancy to one year after delivery or termination), six times as likely to die as Scandinavians. In every other wealthy country, and many less affluent ones, maternal mortality rates have been falling; in Great Britain, the journal Lancet recently noted, the rate has declined so dramatically that "a man is more likely to die while his partner is pregnant than she is." But in the U.S., maternal deaths increased from 2000 to 2014. In a recent analysis by the CDC Foundation, nearly 60 percent of such deaths are preventable.

While maternal mortality is significantly more common among African-Americans, low-income women and in rural areas, pregnancy and childbirth complications kill women of every race and ethnicity, education and income level, in every part of the U.S. ProPublica and NPR spent the last several months scouring social media and other sources, ultimately identifying more than 450 expectant and new mothers who have died since 2011.

They died from cardiomyopathy and other heart problems, massive hemorrhage, blood clots, infections and pregnancy-induced hypertension (preeclampsia) as well as rarer causes. Many died days or weeks after leaving the hospital.

The reasons for higher maternal mortality in the U.S. are manifold. New mothers are older than they used to be, with more complex medical histories. Half of pregnancies in the U.S. are unplanned, so many women don't address chronic health issues beforehand. Greater prevalence of C-sections leads to more life-threatening complications. The fragmented health system makes it harder for new mothers, especially those without good insurance, to get the care they need. Confusion about how to recognize worrisome symptoms and treat obstetric emergencies makes caregivers more prone to error.

Yet the worsening U.S. maternal mortality numbers contrast sharply with the impressive progress in saving babies' lives. Infant mortality has fallen to its lowest point in history, the CDC reports, reflecting 50 years of efforts by the public health community to prevent birth defects, reduce preterm birth, and improve outcomes for very premature infants. The number of babies who die annually in the U.S. — about 23,000 in 2014 — still greatly exceeds the number of expectant and new mothers who die, but the ratio is narrowing.

The divergent trends for mothers and babies highlight a theme that has emerged repeatedly in ProPublica's and NPR's reporting. In recent decades, under the assumption that it had conquered maternal mortality, the American medical system has focused more on fetal and infant safety and survival than on the mother's health and wellbeing.

The growing specialty of maternal-fetal medicine drifted so far toward care of the fetus that as recently as 2012, young doctors who wanted to work in the field didn't have to spend time learning to care for birthing mothers. "The training was quite variable across the U.S.," said Mary D'Alton, chair of ob/gyn at Columbia University Medical Center and author of papers on disparities in care for mothers and infants. "There were some fellows that could finish their maternal-fetal medicine training without ever being in a labor and delivery unit."

In the last decade or so, at least 20 hospitals have established multidisciplinary fetal care centers for babies at high risk for a variety of problems. So far, only one hospital in the U.S. — New York-Presbyterian —has a similar program for high-risk moms-to-be.

In regular maternity wards, too, babies are monitored more closely than mothers during and after birth, maternal health advocates told ProPublica and NPR. Newborns in the slightest danger are whisked off to neonatal intensive care units, staffed by highly trained specialists ready for the worst, while their mothers are tended by nurses and doctors who expect things to be fine and are often unprepared when they aren't.

When women are discharged, they routinely receive information about how to breastfeed and what to do if their newborn is sick but not necessarily how to tell if they need medical attention themselves. "It was only when I had my own child that I realized, 'Oh my goodness. That was completely insufficient information,'" said Elizabeth Howell, professor of obstetrics and gynecology at the Icahn School of Medicine at Mount Sinai Hospital in New York City.

An article recently published in The Online Journal of Issues in Nursing explored these issues. The abstract and excerpts are included here.

People with disabilities use various assistance devices to improve their capacity to lead independent and fulfilling lives. Service dogs can be crucial lifesaving companions for their owners. As the use of service dogs increases, nurses are more likely to encounter them in healthcare settings. Service dogs are often confused with therapy or emotional support dogs. While some of their roles overlap, service dogs have distinct protection under the American Disabilities Act (ADA). Knowing the laws and proper procedures regarding service dogs strengthens the abilities of healthcare providers to deliver holistic, patient-centered care. This article provides background information about use of dogs, and discusses benefits to patients and access challenges for providers. The author reviews ADA laws applicable to service dog use and potential challenges and risks in acute care settings. The role of the healthcare professional is illustrated with an exemplar, along with recommendations for future research and nursing implications related to care of patients with service dogs.

Patients benefit in many ways from service dogs. Healthy People 2020 seeks to improve health and "promote full community participation" for people with disabilities Not only do dogs assist handlers with their disabilities, but they can also provide emotional support (Hubert, Tousignant, Routhier, Corriveau, & Champagne, 2013; Fairman & Huebner, 2000). People with disabilities are more likely than their nondisabled counterparts to feel depressed or have low self-esteem (Collins et al., 2006).

Members of the community smile more at people with service dogs than those who do not have a service dog (Eddy, Hart, & Boltz, 1998; Mader, Hart, & Bergin, 1989). The service dog often eliminates the social barriers that exist for those who have disabilities and this can make a significant difference to the lives of these patients (Mader, Hart, & Bergin, 1989). Studies have shown that people with physical disabilities report people talking to them when they were in public with their dog more often than when they were without their service animal (Lane, McNicholas, & Collis, 1998). These social interactions can facilitate a significant boost in self-esteem for those who have disabilities (Winkle, Crowe, & Hendrix, 2012).

There is often confusion about differences between service dogs and therapy dogs. It is important to be able to distinguish between the two, as their roles are different and the laws surrounding them also vary. Service dogs are not pets: they are working animals (U.S. Department of Justice, 2010; US Department of Health & Human Services, 2016). These dogs are a tool for their handlers, the same as a wheelchair, glucometer, or a pair of glasses are for those who need them.

Service dogs work for one handler and they perform a trained task for that unique handler. Since they perform a trained task, they are protected under the Americans with Disabilities Act ([ADA], 2010; Nondiscrimination on the basis of disabilities in state and local government series, 2010).

Emotional support dogs, whose functions are to provide comfort for their owners, are not covered under the ADA (U.S. Department of Health & Human Services, 2016). Service dogs provide support for their owners, but they must also provide a trained task in order to qualify under the ADA. Psychiatric Service dogs are not emotional support dogs if they perform a trained task (Mills & Yeager, 2012). If the dog has a trained task, such as alerting someone to an oncoming panic attack or reminding a person to take their medication, this skilled task qualifies them as a service dog. This can be a subtle but important distinction.

(Editor’s note: in Massachusetts Emotional Support Dogs are provided protections under housing law, thought not in public accommodations. Emotional Support dogs also are protected in air travel.)

Dogs in public places, including healthcare provider offices, may cause alarm for unknowing bystanders. There may be concern as to the legitimacy of the dog's services and therefore its access to public places. According to the ADA (2010), only two questions about the dog are allowed: "Is that a service dog?" and "What task does the dog perform?" While these questions are vague, they are the only questions that are legally permitted. The patient may respond "yes, he is a service dog and he alerts to a medical condition." The law prohibits asking for any further details or explanation.

While a well-trained service dog is unlikely to be disruptive, it can happen. The cost of professionally trained service dogs often leads to handlers self-training their dogs. There is a lack of nationally mandated standards or certifications. Therefore, it is possible to encounter a dog that is not adequately trained. If the service dog is a threat to the health and safety of others, handlers may be asked to remove the dog from the setting. Removal requests can also occur if the dog is being disruptive, is out of control of the handler, or is not properly house trained (Nondiscrimination on the basis of disabilities in state and local government series, 2010). However, assumptions about the dog's behavior, fear, or mild allergies are not valid reasons to deny access to a service dog. (U.S. Department of Health & Human Services, 2016).

Table 2. Service Dogs and the ADA Laws

Handler can be asked 2 questions only:

Is that a service dog?
What skilled tasks does the service dog perform?

Service dogs can accompany their handler anywhere the public is allowed to go
Service dog must be under handler's control
Handlers cannot be treated differently because they have a service dog
No gear or certification is required
Staff is not required to provide care for the service dog
A service dog may only be asked to leave under the following conditions:

The dog is not house trained
The dog is a threat to others that cannot be reasonably accommodated

The law states that service dogs cannot be denied access with their handlers in public areas that are non-sterile (Grace, 2013). This law applies to not only the patient but also visitors who use service dogs.

The nurse might be concerned about the wellbeing of other patients while a service dog is in the facility. What if another patient is allergic to dogs? What if the nurse is afraid of dogs? Is there an infectious disease risk? These are valid concerns and ones that are often encountered, however, fear of dogs and allergies are not valid reasons to request a service dog be removed (U.S. Department of Health & Human Services, 2016).

Unlike a therapy dog, the service dog is only present in order to assist the handler. Therefore, interaction with other patients and staff should be minimal or absent. Reasonable accommodations can be made to ensure that the patient, service dog, and others are comfortable and safe. If a nurse is fearful or allergic, a simple solution is to change the staffing assignment. If a person has an allergy to dogs that is severe enough that it a limits "one or more major life activity" then the allergy is covered by the ADA. Both parties should receive reasonable accommodations (Denholm, 2009). It is imperative that the patient with a disability who uses a service dog is not isolated or treated differently than others who do not have a service dog (U.S. Department of Health & Human Services, 2016).

It may be tempting for the healthcare team to interact with a service dog, but the dog is working and should not be distracted (U.S. Department of Health & Human Services, 2016). Healthcare providers should not pet or talk to the dog unless granted permission by the handler. Remember that the reason for the dog's presence is to help the disabled partner. The dog should be out of the way so as not to interfere with care being provided. The healthcare team is not responsible for caring for the service dog. If the patient is too ill to care for the dog, it is the patient's responsibility to arrange care for the animal.

It is the role of the healthcare team to incorporate the service dog into a holistic plan of care for the patient. For many patients, their service dog is the link that allows them better access to care and the environment around them. The service dog is an essential lifeline, regardless of whether they are in a medical facility or functioning in daily life. Healthcare providers must acknowledge the benefits of a service animal in order to prevent unacceptable gaps in care.

Editor's note: MGH staff are also welcome to direct questions to the MGH Disabilities manager. e-mail Zary Amirhosseini or call 617-643-7148.