Friday, February 24, 2017

Popular Charity Heart Screenings For Teens May Cause More Problems Than They Solve

By Mary Chris Jaklevic
Kaiser Health News

Content provided by Kaiser Health News

Dozens of not-for-profit organizations have formed in the past decade to promote free or low-cost heart screenings for teens. These groups often claim such tests save lives by finding abnormalities that might pose a risk of sudden cardiac death.

But the efforts are raising concerns. There’s no evidence that screening adolescents with electrocardiograms (ECG) prevents deaths. Sudden cardiac death is rare in young people, and some physicians worry screening kids with no symptoms or family history of disease could do more harm than good. The tests can set off false alarms that can lead to follow-up tests and risky interventions or force some kids to quit sports unnecessarily.

“There are harms that I don’t think a lot of people realize,” said Dr. Kristin Burns, who oversees a two-year-old registry at the National Institutes of Health of sudden deaths in people under 20. It’s one of several efforts aimed at gathering better data about cardiac abnormalities in kids.

Studies using limited data have found between one and four sudden cardiac deaths occur annually per 100,000 kids between ages 1 and 18. By comparison, 22 out of 100,000 U.S. teens are killed in accidents, including those involving motor vehicles, and nine out of 100,000 commit suicide, according to the Centers for Disease Control and Prevention.

Some screening advocates believe sudden cardiac deaths are underreported and not enough is being done to spare families from the fate of losing a child. “We have to acknowledge that every kid who drops dead, they’ve been failed by the current system,” said Darren Sudman, who founded Simon’s Fund, a screening effort in greater Philadelphia in memory of his infant son, who died of an arrhythmia.

Screening programs say they’re educating parents about the risks. “What we want to emphasize is, make sure your kid is heart-safe,” said Dr. Jonathan Drezner, a sports and family medicine specialist in Seattle at UW Medicine and medical director of the local Nick of Time Foundation.

Enthusiasm for ECGs, which measure the electrical activity in the heart to detect abnormalities, grew after a 2006 study showed they lowered death rates among athletes in Italy. But research in other countries has not yielded similar results, and the Italian researchers recently were accused of refusing to share their data so it could be evaluated independently.

Some 60,000 to 70,000 U.S. teens were screened in 2016, most by foundations created by families who lost a child to sudden cardiac death, said Darren Sudman, who runs an online directory, Screen Across America. It’s unclear whether high school athletes face higher risk than non-athletes, so screening programs usually invite everybody.

Screenings typically are held in high schools and overseen by volunteer cardiologists, with funding from individuals and businesses including hospitals. A handful of hospitals and for-profit companies also run screenings.

It may be presumptuous to claim ECGs save lives, but parents often believe they do, said Sudman. “If I find a heart condition, I promise you there are parents who are thanking me for savings their kid’s life.”

That perception is stoked by tragic stories in the media of children who died suddenly after never reporting a symptom. Meanwhile, the drawbacks of ECGs are seldom depicted. As many as 1 in 10 ECGs detects a potential abnormality, and the emotional and financial toll of such a finding can be significant — especially when they turn out to be wrong.

Following a screening ECG and echocardiogram last fall, Daniel Garza, 16, a talented sophomore basketball player in San Antonio, was told he had hypertrophic cardiomyopathy, a thickening of the heart muscle and the most common cause of sudden cardiac death in young people. He was advised to quit all exercise, at least temporarily.

“We were shocked, just shocked,” said his mother, Denise. She said her son became depressed when he couldn’t play the sport he enjoyed and excelled at. “He came home and cried himself to sleep. He said, ‘Mom, why did God give me this gift to take it away?’”

The Garzas traveled to the Mayo Clinic in Rochester, Minn., where further tests indicated his enlarged heart was a benign condition known as athletic heart, a result of intense training. His mother estimates that correcting the misdiagnosis cost more than $20,000, including medical costs, travel and lost work.

Daniel has returned to the basketball court. Still, Denise Garza said the emotional toll was rough. “It was one of the hardest things my family has ever endured.”

Several cardiologists said they often see cases like this or worse. Even after follow-up testing, it can be unclear which cases are life-threatening, so kids with low risk could be restricted from exercise or given life-altering interventions such as implantable defibrillators, surgery or anti-arrhythmic medications.

Medical groups have wrestled with the issue. The American Heart Association and the American College of Cardiology recommended in 2014 against mass ECG screening, noting that sudden cardiac death is rare in teens and false positives generate “excessive and costly second-tier testing.” ECGs also miss at least 1 in 10 cases of hypertrophic cardiomyopathy and more than 9 in 10 cases of congenital anomalies, the second-most-common cause.

But their expert panel accepted voluntary screening “in relatively small cohorts” if there’s physician involvement, quality control and a recognition of unreliable results and ancillary costs.

By contrast, there’s broad support for automated external defibrillators, which have been shown to prevent deaths at schools and other public places. Some foundations focus their efforts on disseminating the defibrillators.

One problem with ECGs is a lack of good data.

“There’s no evidence we have that ECG screening saves lives,” said Dr. Jonathan Kaltman of the NIH’s National Heart, Lung, and Blood Institute. “There’s never been a controlled clinical trial, which is the only way to answer that question.”

Efforts are underway to improve the accuracy of the screening programs. Some are adding echocardiograms, which use ultrasound to produce images of the heart, to verify potential abnormalities. Advocates say false positives have dropped as a result of better interpretation guidelines, known as the Seattle Criteria, which are expected to soon be endorsed by cardiology societies in revised form.

But the criteria are not perfect, and there’s a “giant gap” in training cardiologists to use them, said Drezner, one of the developers. He’s also a medical adviser for Parent Heart Watch, a consortium of foundations. “If I was a parent, I’d want to know about the experience of the (cardiologists) and what they’re going to do to help my kid if they have a positive screen.”

At the urging of screening advocates, the NIH partnered with the Centers for Disease Control and Prevention to rigorously track cardiac deaths as part of a Sudden Death in the Young Case Registry. So far a handful of states and counties have joined the effort, which helps local health departments collect better data. The goal is to standardize death investigations and get a firm handle on how often kids die from heart abnormalities as well as the role of factors such as genetics. Initial findings are expected to be available in about two years. The NIH is also funding three university-based research groups to answer key questions about sudden cardiac death in the young.

Some screening organizations are getting behind a nascent initiative with the Cardiac Safety Research Consortium to harness their own screening data for research. It would require standardizing their practices and tracking outcomes, which organizations aren’t now equipped to do.

“Screening is happening. We can’t avoid that,” said Dr. Salim Idriss, director of pediatric electrophysiology at Duke University and co-chair of the initiative. “We have a really good opportunity to get the data we need to make it better.”

Separately, the UT Southwestern Medical Center in Dallas recently began a four-year pilot study involving athletes and band members at eight high schools to determine the feasibility of a full-scale randomized controlled trial.

A valid finding on the overarching question of whether ECG screening saves lives could require at least 800,000 participants and a cost of $15 million, said Dr. Benjamin Levine, a cardiologist and the lead researcher.

The pilot is partly a response to legislation that would mandate ECGs for student athletes in Texas. A similar bill was also introduced in South Carolina. Both bills failed, but it’s expected there will be more attempts to mandate ECGs, leaving state legislators looking for better guidance.

“We’re not going to solve this by having more debates, but by having more data,” Levine said.

This article was produced by Kaiser Health News

Thursday, February 16, 2017

Texas Doctors’ Prescription for the 2017 Legislature

By Ray Callas, MD
Beaumont Anesthesiologist
Chair, Texas Medical Association Council on Legislation

Growing state and federal government regulations and insurance company mandates are stealing time Texas physicians should spend with our patients. This is unacceptable. Every minute my colleagues and I spend with a patient is a minute that matters. This is why we have dedicated ourselves to tirelessly advocating for legislation that allows us to spend more quality time with our patients, foster the critical patient-physician relationship, and provide care in the manner in which we were trained.
With the 85th Texas legislative session underway, the Texas Medical Association (TMA), comprised of more than 50,000 doctors and medical school students who are caring for our state’s 27 million citizens, is urging lawmakers to take specific actions to help improve patient care. We encourage you to join us in making state legislature calls and/or to write to or call your legislator to push for the quality care that all Texans deserve.

Our 2017 prescription to keep Texas healthy includes:


1. Enact a Texas-Run Health Care Solution for Our Low-Income Families, Seniors, and Texans with Disabilities
  • Protect coverage and access to health services for our most vulnerable populations.
  • Set physicians’ Medicaid payment rates at least equal to Medicare.
  • Cover Texas’ one million-plus uninsured with private insurance that includes copays, tailored benefits, and health savings accounts.
  • Modernize the Medicaid Vendor Drug Program and improve Medicaid prior authorization requirements to cut regulative red tape.


2. Stop Health Insurance Tactics That Cause Surprise Medical Bills
  • Require health plans to comply with current network adequacy requirements and provide accurate directories of their network providers.
  • Expand the current mediation process, while maintaining the $500 threshold, to all physicians and providers providing out-of-network services at certain in-network facilities, and to certain out-of-network scenarios where patients are receiving surprise bills for emergency care.
  • Allow physicians to override health plans’ use of “step therapy” to substitute prescribed drugs for chronically ill patients.

3. Invest Wisely In Mental Health, Public Health, and Public Safety Programs
  • Ensure parents’ right to know about vaccination exemption rates at their children’s schools. 
  • Improve access to quality mental health care services.
  • Increase minimum age to buy tobacco products to 21.
  • Ban texting while driving.
  • Make state higher education and state agency campuses tobacco free.

4. Use Technology — Not Mandates — To Address “Doctor Shopping” and Opioid Diversion
  • Require prescriber licensing boards to automatically register their licensees for Texas’ Prescription Drug Monitoring Program.
  • Authorize the Board of Pharmacy to “push out” electronic notifications to prescribers and pharmacies when data suggests “doctor shopping.”
  • Add wholesaler delivery data to the Drug Monitoring Program database in order to match dispensing and delivery data by geographic area.

5. Require Same Standard of Medical Care Whether In-Person or by Telemedicine 
  • Physicians providing care to Texans must be licensed in Texas.
  • Ensure that physicians have access to the patient’s relevant clinical information in order to make a diagnosis and conform to the standard of care. 
  • A medically necessary, covered service should be paid for regardless of how it is provided.

6. Support a Strong and Fair Texas Medical Board (TMB) and Stop Diverting Physician License Fee Revenue
  • Continue and improve the TMB to ensure appropriate and safe regulation for the practice of medicine.
  • Medical Board discipline procedure needs to protect patients and guarantee physicians a transparent, fair process.
  • Stop diverting physician license fee revenue to the general fund. Instead, reduce the fee and use all funds collected to improve the Medical Board and speed up Texas medical licensing, which can take more than 12 months for the entire application process.

7. Require Medical School Training and Licensure for All Who Practice Medicine
  • Diagnoses and prescriptive authority must remain the purview of medical-school-trained, licensed physicians.

8. Protect Our State’s Medical Liability Tort Reform Caps
  • Since statewide voter approval of non-economic medical liability damage caps in 2003, Texas has gained 21,000 new physicians. Protecting these caps will help our state continue to improve upon our national ranking of 41st in active patient care physicians per capita. 

9. Keep Our Texas-Trained Doctors in Texas
  • Ensure we have 1.1 Texas residency slots for every one Texas medical school graduate.

The TMA and our physician members are fighting every day to ensure that we are putting patients first and are working to protect the personal health of all Texans. We are ready to provide counsel and advice or answer any questions you may have on these issues or others. We encourage you to reach out at (800) 880-7955 or connect with us on Facebook or Twitter @TexMed to engage and learn more.

Tuesday, February 14, 2017

“I Vaccinate You Because I Love You”

This Valentine’s Day, physicians are encouraging parents to show their children how much they love them by vaccinating them against contagious and sometimes deadly diseases like influenza, measles, HPV, and whooping cough. Because when you love someone, you do all you can to keep them safe and healthy.

New York state internist Fran Ganz-Lord, MD, says vaccinating your kids is one of the greatest acts of love. She relayed the following story on a physician-mothers Facebook group, (posted with permission):
“Today I took my 3 girls in for physicals and flu shots. Oldest also needed a TdaP and was freaking out. I got one inch from her face with a smile, put one hand over her heart, held her head steady with the other and looked right into her eyes and as they gave her two shots I said, "I vaccinate you because I love you...because I love you." Those that know me will attest that I'm not so corny/warm and fuzzy all the time — but my best friend died two-and-a-half years ago of influenza. The oldest is the only one who remembers/knows...she started to cry.”
Dr. Ganz-Lord’s powerful message resonated deeply with fellow physician mother Leilani Valdes, MD, a Victoria, Texas pathologist and member of TMA’s Be Wise—ImmunizeSM panel. Dr. Valdes shared Dr. Ganz-Lord’s story with her colleagues. “I will use, “I vaccinate you because I love you” when I take my kids to get vaccinated from now on!” she said.


Monday, February 13, 2017

Raising the Minimum Age Tobacco-Use Age to 21 Will Save Texas Lives, Money

In a lean legislative budget year (such as this one), opportunities to save the state money — while also saving lives — should get top priority, say Texas physicians. Enter Tobacco 21 or T-21, an initiative that aims to save Texas billions of dollars and thousands of lives by raising the minimum age of tobacco use to 21 years.

Physicians say the measure will significantly curtail the use of tobacco products in people ages 18-20, and help reduce the likelihood that young people become lifelong smokers. Ronald DePinho, MD, president of The University of Texas MD Anderson Cancer Center, promoted Tobacco 21 to legislative staff and fellow health leaders last week at the Texas Medical Association during the the “University of Health” briefing sponsored by the Texas Public Health Coalition, a group of 35 health-promoting organizations.

Curtailing tobacco use is “the single most important opportunity” to reduce cancer deaths in Texas, said Dr. DePinho. “It trumps everything else combined. We are going to lose a billion lives [worldwide] over the next 100 years [to tobacco-related illnesses]. It’s the only product that when used as intended extracts a very significant social, economic, and personal toll.”

Tobacco use is the leading cause of preventable death in the United States. In Texas alone, about 24,500 adults per year die of tobacco-related causes, and taxpayers lose an estimated $12.2 billion annually due to excess medical care expenditures and lost productivity. Ninety-five percent of smokers in the United States begin smoking before they turn 21, and 80 percent begin before age 18. As many as 500,000 premature deaths could be prevented by year 2100 by raising the minimum age for buying tobacco to 21 nationally. Hawaii, California, and more than 200 localities including New York City and Chicago already have banned the sale of tobacco products to those under 21.

Several bills have been filed by both Democrats and Republicans in the Texas Legislature to raise the minimum smoking age to 21, and the T-21 bills are expected to be filed next week. Physicians are hopeful this is the year the legislation passes.

“This is an enormous opportunity, and there is overwhelming support for this across the political spectrum from the very conservative to extremely progressive,” Dr. DePinho said. “I cannot think of a single thing that would be more impactful for our generation to give to future generations to come.”
The Tobacco 21 initiative is supported by MD Anderson’s Cancer Moon Shots Program, which aims to “rapidly and dramatically reduce mortality and suffering in several major cancers.”

Thursday, January 26, 2017

The Following Sentence Might Save Someone’s Life

David Lakey, MD
Chair, TMA Council on Science and Public Health
Chief Medical Officer and Associate Vice Chancellor for Public Health, UT System

Barbara J. Turner, MD
Director, Center for Research to Advance Community Health at UT Health San Antonio

This article was originally published at The Huffington Post and is reprinted here with permission.

The following sentence might save someone’s life. There are millions of Americans with a serious, life-threatening virus that can be cured, within roughly 12 weeks, if they simply get tested and find out they have it.

The virus is Hepatitis C (HCV), which chronically infects an estimated 2.3 million Americans. It’s the leading cause of both cirrhosis and hepatocellular carcinoma (HCC), the most common type of primary liver cancer.

Overall death due to Hepatitis C is at an all-time high nationally. In fact, the death rate for HCV exceeds death rates from all other top-60 infectious diseases combined, including HIV and tuberculosis.

Yet infection typically only causes vague symptoms until it gets very advanced, which can take decades. Consequently, many people with the virus don’t know it. In fact only roughly half of the people who have the virus are aware of it.

That’s the bad news. The good news is that most serious complications from HCV infection can be averted, once the infection is diagnosed. There are new, direct-acting, all-oral anti-HCV drugs that work extraordinarily well.

A 2015 study published in Clinical Liver Disease shows that these drugs can cure more than 90 percent of chronically HCV-infected people, on average, within three months. A 2016 study published in the Journal of Hepatology found that these medications increased the life expectancy of patients with HCV-caused cirrhosis to be similar to that of the general population.

So there’s excellent treatment. In order for that treatment to save as many lives as possible, however, we need to dramatically increase awareness. We need people to get a blood test to check for the infection.

The U.S. Preventative Services Task Force (USPSTF) has endorsed a one-time screening of all Americans born from 1945 to 1965 (i.e. baby boomers) for HCV because 75 percent of people living with HCV are in this age range.

Although the prevalence of infection in all baby boomers is high, studies show African-Americans have an even higher risk of chronic HCV. Additionally, our own research, recently published in Hepatology, shows that Hispanics are more likely to have advanced HCV-related liver disease at diagnosis.

Most health insurers now cover HCV screening tests for baby boomers. Yet currently only about 10 percent of baby boomers have been tested, because most clinical practices have not developed the infrastructure to perform screening and linkage to care.

Here in Texas we were able to develop a continuum of screening and care, with funding by the Centers for Disease Control, that tested more than 90 percent of eligible baby boomers who were admitted to University Hospital in San Antonio. Of those 4,582 patients, we diagnosed 175 (4 percent) with chronic HCV and were able to link the majority to outpatient care.

We have also tested more than 15,000 baby boomers in over 15 primary care practices throughout the state through a team-based model of care that provides screening followed by education and HCV care for persons who are newly diagnosed with chronic HCV. Our group and others have found that primary care clinicians can successfully treat chronic HCV with training and support from specialists because the medications are very well tolerated and the treatment usually lasts only 12 weeks.

We would be delighted to share our materials and methods, and we encourage others to join us in the collective effort to reverse the significant health threats from HCV and HCC.

It’s going to take time to integrate comprehensive HCV screening and referral into health care on a national scale, but it is entirely achievable. The faster we do this, the more lives we’ll save. Think of the fathers, mothers, relatives, close friends, and colleagues who are unaware of having a potentially deadly infection but, once diagnosed, can be cured.

Editor's Note: Promoting HCV education and screening tests is a focus of Texas HepCA, a team of oncologists and hepatologists led by Gerard Voorhees, MD, Chair of the Texas Medical Association (TMA) Committee on Cancer, and Howard Monsour, MD. The group targets HCC education efforts to primary care physicians and the general public, and offers physicians free in-person continuing medical education (CME) to county medical societies across the state.

Wednesday, January 11, 2017

TMA Raises Physician Awareness of Human Trafficking

Editor's Note: In recognition of National Human Trafficking Awareness Day today, we are republishing this story from February 2016. This article was updated to reflect passage of a TMA resolution to raise physician awareness of human trafficking, and to include information about continuing medical education (CME) for physicians on human trafficking at TexMed 2017, TMA's annual physician conference.

Some victims of human trafficking are walking into physicians’ offices, and many doctors believe these visits put the doctor in a unique position to help them escape sexual labor and slavery, reports Texas Medicine magazine, the monthly publication of the Texas Medical Association (TMA).

Last year, TMA passed a resolution to help.

While it happens in many states, Texas is one prominent epicenter of the U.S. human trafficking trade, accounting for nearly one-tenth of the National Human Trafficking Resource Center’s tip calls in 2014. A 2008 Texas Attorney General report said nearly 20 percent of human trafficking victims found nationwide had been in Texas. And Texas Gov. Greg Abbott recently proclaimed January 2016 Human Trafficking Prevention Month.

Reports show many of these victims visit physicians, most commonly in emergency departments and urgent care centers. One such report compiled responses from a series of focus groups of female sexual trafficking survivors. Of those survivors who answered questions about their health care, nearly 88 percent told the winter 2014 Annals of Health Law they had contact with a health care practitioner while being trafficked.

Some physicians see those visits as opportune for helping the victims escape their situation.

“Medical providers are some of the only professionals that victims of human trafficking come in contact with during their period of slavery,” said obstetrician-gynecologist Melinda Lopez, MD, who founded and ran a clinic for sexual trafficking victims in Austin in 2013-14. “So we are really a window of opportunity for these people who are seeking access to services and to escape their situation. When we’re not able to pick up on some of those [signs] ourselves or even know what the risk factors are, or what to do with those after we do identify them, we’re missing that opportunity.”

Arlo Weltge, MD, vice speaker of TMA’s House of Delegates, said a resolution to raise physicians’ awareness of trafficking was a step in the right direction, because once physicians know what to look for, they’ll begin to recognize when a potential victim shows up in their exam room. TMA’s Medical Student Section introduced the resolution and the TMA House of Delegates, the organization's policy-making body, passed it during TexMed 2016, TMA's annual meeting.

To continue the progress physicians are making to help victims of human trafficking, TMA is offering continuing medical education (CME) at this year's TexMed in Houston.

David Gruber, assistant commissioner for regional and local health services at the Texas Department of State Health Services, told Texas Medicine more physician involvement in identifying trafficking victims and taking subsequent action represents “an opportunity to intervene, to break the chain of events.”

“I can compare it to being primed for Ebola or a highly contagious infectious disease or the doctor in Florida who identified the anthrax case way back in 2001,” he said. “If you’re attuned to something, you have a better chance of being able to recognize it. So if we can educate those in the medical community on signs and symptoms, much like we do for signs and symptoms of disease, then there’s a chance to do some good.”

Wednesday, January 4, 2017

Medical Students Help Provide Health Care for Refugees

By Wendy Rigby
Texas Public Radio


This article originally appeared on Texas Public Radio and has been republished here with permission.

Each Wednesday at St. Francis Episcopal Church on the north side of San Antonio, dozens of refugees from all over the world come for free care at the Refugee Health Clinic.

Students and faculty at the University of Texas Health Science Center in San Antonio have teamed up to operate one of the only student-run refugee clinics in the country.

In the past six years, more refugees have resettled in Texas than in any other state. That was before the state of Texas pulled out of the refugee resettlement program in September, citing concerns over terrorism.

The refugees who come seeking care are from the Middle East, southern Africa and Asia. They have fled violence and persecution. An estimated 5,000 refugees live within 3 miles of San Antonio's medical center.

Most who have resettled here receive temporary federal government health benefits that run out after six months or so.

"We really fill that gap before they can kind of get on their feet after they've lost their government benefits," says Michael Tcheyan, a medical student who volunteers at the clinic. "We feel like it's our duty, and it's their right to get medical care and to be connected with services that are going to make their life better."

Medical students from the Student Faculty Collaborative Practice of UT Health San Antonio help provide care along with students from the School of Nursing, the School of Dentistry and the School of Allied Health Professions, which includes physician assistants, physical therapy and respiratory care.

Layla Mohsin, 52, came to the clinic for dental care. She's a teacher from Iraq who came to the U.S. with her family of seven to escape the violence.

"We left Iraq and came to the United States because there is safety here. There, there is no safety," Mohsin says as her son, Karrar Al Gburi, interprets for her. "The main concern? The lethal explosive cars. You can get caught by an explosive car at any place, any time."

Laxmi Adhikari, a 65-year-old old man who fled Bhutan to a refugee camp in Nepal, is being treated for an itchy stubborn rash. He sports a T-shirt with a local high school team logo, a gift from one of the many people in San Antonio who he says have welcomed him.

"It's far better than the refugee camp," Adhikari says through Nepalese interpreter Dal Gajmer. "I trust and believe all of the nurses and doctors. They treat me very well."

Dental student Eduardo Vela is originally from another country, too. He understands his patients' challenges. "If you don't know the language, there are a lot of cultural differences. I myself grew up in Mexico, so I know a little bit of the feeling of being an outsider and then trying to fit in," Vela says.

The refugee population has many unmet medical needs, says clinic medical director Browning Wayman. "They are in search of people to manage their high blood pressure, their diabetes, their high cholesterol, thyroid disease, mental health issues," Wayman explains. "For a lot of us that went into medicine, we went into it to help people. This is a population that needs help, and so it's really a joy."

Funding for the Refugee Health Clinic is provided through the Kronkosky Charitable Foundation and St. Luke's Lutheran Health Ministries Inc., as well as the operations budget of the Center for Medical Humanities and Ethics, part of the School of Medicine of the University of Texas Health Science Center at San Antonio. Endowment funds, individual donors and the university pitch in to cover other costs.

Texas will continue to be home to new refugees. But instead of giving financial assistance to the state, the federal Office of Refugee Resettlement will be giving that money directly to nonprofits.

The refugees don't use the free clinic forever. The staff helps them find more permanent care. If patients need a referral to a specialist, they may have to find a way to pay for that visit.

The students and faculty also work to connect patients to whatever health coverage they might be eligible for, such as CareLink, a financial assistance program for health care services through University Health System. It's available for Bexar County residents who do not have public or private health insurance. The cost is based on family size and income.

Navigating the health care system can be difficult even for Americans, says one of the clinic's founders, Dr. Andrew Muck, an associate professor of emergency medicine at UT Health Science Center, so he says it is hard to imagine the difficulty for these refugees.

"You don't speak the language, may not have a job," Muck says. "And even though you're in the midst of this robust health system, you can't get in the door, can't get over those hurdles."
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