CMS Dumps Marketing and Other Rules for Medicare Advantage Plans, Pleasing Industry

 by Cheryl Clark

In an effort to remove what it considers burdensome and unnecessary rules, the Centers for Medicare & Medicaid Services (CMS) finalized a package of polices for Medicare Advantage (MA) plans for 2027 that it hopes will improve care and reduce red tape and confusion for beneficiaries and insurance companies.

"We are moving away from a system that incentivizes administrative box-checking and are instead laser-focused on what truly matters: the clinical outcomes and health of our beneficiaries," Chris Klomp, director of Medicare and deputy administrator at CMS, said in a press release.

But David Lipschutz, co-director of law and policy at the Center for Medicare Advocacy, called several of the 219-page rule's provisions "a rollback of consumer protections, which gives in to pressures from the insurance industry and those who sell their products."

One significant example affecting doctors, Lipschutz said, was that CMS in its November proposed rule seemed ready to grant a much needed special enrollment period (SEP) for patients when their providers were terminated from plan networks outside of open enrollment windows, with no need for a determination that the network changes were "significant." Patients could then switch to a different plan or traditional Medicare to keep seeing the same clinicians, and could also purchase a Medigap supplemental plan without underwriting.

MA plan terminations of physician and other provider contracts -- due to financial or other disputes -- are frustrating and potentially harmful for enrollees who suddenly find themselves scrambling to find care from appropriate new providers.

CMS acknowledged the broad interest in the new SEP but said it would not finalize that proposal and would not address numerous stakeholder comments related to it.

Not having that SEP is especially hard on doctors who want to keep their patients, Lipschutz said. "If your Medicare Advantage plan terminates you mid-year, CMS is not making it easier for patients to follow you," he noted.

Insurance industry representatives were generally pleased with the new provisions. On the marketing rule changes, Susan Reilly, spokeswoman for Better Medicare Alliance, which promotes MA plans, said, "We've long called for streamlining rules while strengthening TPMO [third-party marketing organizations] oversight and enforcement, and the final rule is consistent with that."

The changes also include a repeal of a CMS requirement that health plan marketing agents inform beneficiaries about federally funded State Health Insurance Assistance Program (SHIP) counselors who can provide "information on all your options."

CMS had mandated that agents include that disclosure in 2023 because some agents representing TPMOs were misleading beneficiaries about all their options in order to sell their own plans and reap commissions. SHIPs, the agency said at the time, provide beneficiaries with an "important and unbiased resource for assistance."

The SHIPs also have been an option for physicians who rarely have time or expertise to advise patients each year on which of the dozens of available plans would best suit their needs.

But in its final rule, the agency said the SHIP disclosure was no longer necessary and criticized its operation, noting that it "recognized that, while SHIPs can be a source of unbiased information about plan choices ... SHIP volunteers may not always have the expertise to help beneficiaries navigate increasingly complex MA and Part D programs."

The agency added that each SHIP "works differently and provides different training to its counselors, which can vary further at the local level. This can result in Medicare beneficiaries receiving different information based on the SHIP and SHIP counselor that is ultimately reached."

Rather, CMS said, beneficiaries "may be more effectively served by information and entities for which CMS has direct oversight," adding that 1-800-MEDICARE "is a better option to assist beneficiaries with healthcare choices."

At least one SHIP director did not agree with the disclosure's deletion. Sophie Exdell, MPH, program manager of the San Diego Health Insurance Counseling & Advocacy Program (HICAP), said 1-800-MEDICARE is not the answer. The agency does not have "the training or resources to counsel beneficiaries in much detail, especially on the local plan landscape," she said.

For example, when enrollees in UC San Diego Health's MA plan lost access to their primary care doctors, HICAP created fact sheets to guide them. Medicare counselors had no familiarity with the situation, and the Medicare Plan Finder was not helpful, Exdell said.

The agency also eliminated 11 metrics used to calculate MA plan star ratings, effective in 2029, and declined to implement a scheduled Biden-era measure called the "health equity index," and three other health disparity measures designed to incentivize care for low-income and other underserved beneficiaries. The ratings determine plan bonuses and help beneficiaries compare plans.

The retired metrics also include a measure tracking whether plans make timely decisions about appeals and whether they have good care management for enrollees with special needs, a foreign language interpreter in their call center, and rates on which members choose to leave the plan. The agency gave multiple reasons for their removal. For example, for members leaving the plan, it said it is difficult to know the reason for disenrollment.

The final rule also issued a requirement that debit cards with cash, often used by insurance companies to market their plans, must be electronically linked to plan-covered services and products to stop beneficiaries from using them for non-covered items. The rule also includes lengthy lists of covered products (i.e., antacids or fiber supplements) versus not-covered products (i.e., bad breath remedies or shampoo).

CMS also removed a 2023 prohibition against MA plans using superlatives in marketing materials saying it is unnecessary because plans are already prohibited from making "misleading, confusing, or materially inaccurate" claims. In the spirit of encouraging competition, plans will now be able to say they are the "highest rated," "largest provider network," or "highest rated plan," as long as they can back it up -- for example, giving the relevant period for the claim.

The agency also is relaxing or doing away with several restrictions on how and when brokers and agents can interact with beneficiaries, rules intended to reduce aggressive sales pressure on unwitting beneficiaries. For example, it is deleting a Biden-era requirement imposing a 12-hour gap between a health plan education session and a health plan marketing session in the same location, so that beneficiaries who came to learn about Medicare overall would not suddenly be pressured to enroll.

CMS reasoned that beneficiaries have backup from caregivers accompanying them, "a built-in layer" of protection from such pressure.

Lipschutz was skeptical. "What about people who don't have people with them? That makes them more of a target," he said.

https://www.medpagetoday.com/publichealthpolicy/medicare/120718

'AP: Too Young for the MMR Shot, Babies Become 'Sitting Ducks' in Measles Outbreaks'

 With baby Arthur too young for the measles vaccine and a sibling due in June, the Otwells grew nervous when the threat of the highly contagious virus started factoring into their grocery run.

"We go to the Costco that was kind of a hotbed," said John Otwell, who knew about the state health department's warnings of public exposures at the store. "A lot of people just don't get it; they think it's just a cold. It's not."

By Arthur's 9-month checkup, the South Carolina outbreak had exploded into the nation's worst in more than 35 years, surpassing last year's in Texas. That meant that under state guidance, Arthur could get his first dose of the MMR vaccine -- for measles, mumps, and rubella -- earlier than the usual 12 to 15 months old. Their new baby won't be able to get the shot until at least 6 months -- a prospect that worries parents of infants wherever measles spreads.

Babies too young to be vaccinated are among the most vulnerable in a measles outbreak. The disease can wreak havoc on their fragile bodies, making them so sick they stop eating and drinking. They can develop pneumonia or brain swelling, and sometimes die.

Babies depend entirely on herd immunity -- at least 95% of a community must be vaccinated to prevent measles outbreaks. But dropping vaccination rates have eroded protection in South Carolina and across the nation. In Spartanburg County, the outbreak's epicenter, less than 90% of students have gotten required vaccines.

"Babies become sitting ducks," said Deborah Greenhouse, MD, a Columbia pediatrician. "The burden is on all of us to protect all of us."

But increasingly, some policymakers and officials push a view of vaccination as an issue of individual freedom and parents' rights, rather than one of public health to safeguard the population as a whole.

At the federal level, Health Secretary Robert F. Kennedy Jr., a longtime anti-vaccine crusader, has sought to remake vaccine policy and oversaw billions in public health cuts. And though a temporary ruling from a federal judge has slowed his momentum, a raft of bills has been introduced in states, including South Carolina, that threaten to further reduce vaccination rates.

South Carolina's measles outbreak, totaling about 1,000 cases, has slowed. But measles is spreading in many states, with 17 outbreaks this year and 48 last year, and the U.S. on the verge of losing its status as a country that has eliminated measles.

Doctors Work to Protect the Youngest Against Measles

Jessica Early, MD, never thought she'd have to deal with measles, but the pediatrician feared for her patients and her own baby when it popped up in her Greer community. She and other doctors began offering an approved infant MMR dose as early as 6 months old. Her practice also started giving the second MMR dose -- usually for ages 4 to 6 years old -- early.

To the chagrin of many doctors, no one knows how many South Carolina infants have gotten measles or been hospitalized by it.

State officials will disclose only that 253 of the 997 cases were among children 4 and younger; they say they won't break cases down further for confidentiality reasons. It's not uncommon to group statistics this way.

Officials also don't know exactly how many infants were hospitalized with the virus because, as in some other states, hospitals aren't required to report measles-related admissions.

Across the state, doctors said they got many questions about whether it was safe to bring infants to waiting rooms or day care.

Thomas Compton -- regional director of Miss Tammy's Little Learning Center, a child care network operating across the outbreak region -- said 18 parents pulled children out of his facilities, though they had no confirmed cases. Some abandoned deposits days before their kids were scheduled to start, forcing the company to lay off a teacher.

Although licensed day cares must require vaccines under state law, families can easily get religious exemptions. About a fifth of Miss Tammy's 300 children have vaccine waivers.

When measles surged, Compton said state officials gave little guidance. His staff scrubbed down surfaces, as they did when COVID-19 was raging; tracked local measles cases on Facebook; and relied on Google for information about the disease.

"A lot of parents were really stressed out," Compton said. "Anytime that we had a little sickness going on or something, they were like, 'Do you think it's the measles?'"

State Legislation Would Prohibit Vaccines for Children Under 2

Last year, an Associated Press investigation found that Trump administration officials were directing activists to push anti-science legislation in statehouses. Nationally, around 350 anti-vaccine bills were introduced as of late October, AP found, including at least eight in South Carolina.

This year, a state bill would prohibit requiring vaccines for children under 2.

"In other words, it would get rid of those requirements in the day cares," pediatrician Greenhouse said. "And for people like me, that is a gut punch that is terrifying."

In a subcommittee discussion, Republican State Sen. Carlisle Kennedy said his bill aims to protect parents' rights. His baby was born in August without working kidneys and got vaccines on a personalized schedule, in coordination with doctors.

"We didn't want to put vaccines in his body before his body was able to survive them," he said.

Opponents countered that herd immunity protects children in these situations.

The Senate subcommittee advanced the legislation. Greenhouse fears it has momentum.

"In the climate that we are currently living in, I think any bill potentially could have legs," she said. "It is our job to do our absolute best to make sure that those legs don't go anywhere."

Whether the bill becomes law, doctors say this sort of legislation fuels vaccine skepticism and confusion. While the American Academy of Pediatrics advises giving babies all the vaccines they've gotten for years, some parents tell Greenhouse they know the government has called for fewer.

"They don't actually know who they can trust," she said.

South Carolina, like other states, has made nonmedical vaccine exemptions easier to get, noted Martha Edwards, MD, president of the state's American Academy of Pediatrics chapter. In the outbreak's epicenter, religious exemptions have more than doubled since 2020. Statewide, 4% of school-age students have such exemptions in 2025-26.

"Parental choice is a big buzzword in a lot of the Southern states," Edwards said. But the choice not to vaccinate, she said, impacts other parents' rights to keep their children safe.

Nationwide, Protection Fades as Measles Spreads

Doctors expect things will only get worse.

In the first 3 months of 2026, the U.S. logged 1,671 measles cases. That's 73% of the total from 2025, the worst year for the virus in more than three decades. In November, international health officials will determine whether measles is still considered eliminated in the U.S.

National MMR vaccination rates – which dropped to 92.5% among kindergartners in the 2024-25 school year, from 95.2% in 2019-20 – obscure much lower rates in certain communities. At one Spartanburg County school, 21% of kids received all required vaccines.

Doctors worry it's just a matter of time before all sorts of vaccine-preventable diseases threaten lives like they did a century ago.

"The whole concept of immunization is one of the best things that has ever happened to medicine," Greenhouse said. "To see that we are actually going backwards is just confounding."

Helen Kaiser, who lives in the outbreak area, vaccinated her twin 2-year-old boys early to protect them and the community.

"I would never forgive myself," she said, "if I knew that my son had gotten another baby very sick and it was something I could have prevented."

https://www.medpagetoday.com/pediatrics/generalpediatrics/120731

'AI and the New Folie a Deux'

 Artificial intelligence (AI) is rapidly becoming part of our patients' inner lives. In medical practice, we are accustomed to asking about relationships, stressors, substances, and sleep. Increasingly, however, we must also ask about conversations, not with friends or family, but with chatbots. These exchanges are private, persuasive, and often emotionally charged. And for some patients, they may function less like a search engine and more like a psychological partner.

A useful metaphor comes from the classic psychopathology of "folie à deux," or shared psychotic disorder. Traditionally, this condition describes a dominant individual who transmits a delusional belief to a more suggestible partner. The delusion is sustained not by evidence but by mutual reinforcement. Two people, one belief system, increasingly sealed off from correction.

What happens when one member of the dyad is not a person, but an algorithm?

The Digital Dyad

Large language models are designed to be responsive and affirming. They detect tone, mirror language, and generate replies that feel attentive and empathic. In most contexts, this responsiveness is experienced as helpful. But in the psychiatric domain, affirmation can become amplification.

A patient expresses a suspicion about a partner's betrayal, a coworker's conspiracy, a missed medical diagnosis. The system responds with validation framed as understanding:

"That must feel frightening."

"Given what you've described, your concerns make sense."

Even subtle reinforcement can increase salience and coherence of a belief.

Unlike a clinician, the model does not assess reality testing. It does not introduce alternative hypotheses unless prompted. It does not weigh collateral information. Its task is to continue the conversation in a way that aligns with the user's perspective.

The result can resemble a technologically mediated folie à deux: a closed loop in which belief and validation feed one another. The algorithm does not originate the delusion, but it may stabilize and elaborate it, as sometimes occurs in folie à deux when the suggestible individual embellishes the delusions of the dominant, psychotic partner.

Simulated Empathy and Emotional Attachment

Another psychiatric dimension that deserves attention is simulated empathy. Patients often report that chatbots feel patient, nonjudgmental, and endlessly available. For individuals who are socially isolated, depressed, or mistrustful, this can be powerfully attractive. The chatbot does not interrupt. It does not appear rushed. It does not bill by the hour.

Over time, an attachment may form, not because the machine understands, but because it reliably responds. In vulnerable patients, this can blur the boundary between simulation and relationship. The system becomes a confidant, a validator, even a moral sounding board. In transference terms, the algorithm may become an idealized other: consistently affirming, rarely challenging, and never fatigued. That is not therapy. It is a reinforcement engine.

Pre-Validated Narratives in the Exam Room

Clinicians may notice a change in interactions with patients highly engaged with chatbots. They present not only with symptoms, but with well-developed explanatory narratives. These narratives are often internally consistent, emotionally compelling, and already "vetted" by prior AI conversations.

"I asked the chatbot, and it agreed this is narcissistic abuse."

"It said my doctor might be missing something serious."

"It confirmed that my reaction was justified."

Such statements do not prove distortion. Patients have always sought outside opinions. What is new is the scale, speed, and stylistic authority of the feedback. A single evening of iterative prompting can generate a highly elaborated account that feels objective because it was produced by a machine. For patients with anxiety disorders, personality disorders, or emerging psychosis, this pre-validation may harden cognitive distortions before they ever reach the doctor's office.

The Risk to Reality Testing

Psychiatric treatment often involves cultivating uncertainty: helping patients tolerate ambiguity, consider alternative interpretations, and revise strongly held assumptions. The therapeutic frame introduces friction in service of insight. An affirming algorithm introduces the opposite dynamic. It reduces friction. It optimizes for conversational flow and user satisfaction. Thus, it may inadvertently strengthen confirmation bias.

In a classic folie à deux, separation of the pair can weaken the shared delusion. In a digital variant, separation may be harder. The chatbot is available at all hours. It does not contradict unless specifically engineered to do so. It learns the user's preferences and adapts accordingly. We are therefore confronted with a new clinical variable: not merely misinformation, but relational reinforcement of distorted beliefs.

Expanding the Psychiatric Interview

It may be time to normalize questions such as:

Have you discussed this concern with an AI chatbot?

What feedback did it give you?

How did that response affect how certain you feel?

These inquiries are not accusatory. They are analogous to asking about online forums, social media, or alternative therapies. AI is now part of the patient's cognitive ecosystem. Ignoring it leaves an important influence unexamined.

In some cases, reviewing an AI exchange together may be therapeutically useful. The output can become material for cognitive restructuring: Where does the response validate emotion appropriately? Where does it assume facts not in evidence? What alternative explanations were omitted? Used this way, the technology becomes a clinical artifact rather than a hidden co-therapist.

Design, Responsibility, and Mental Health

The deeper issue extends beyond individual encounters. Many systems are optimized for engagement and keeping users interacting. Agreement and affirmation promote continued use. Challenge and contradiction risk disengagement.

Yet, in mental health contexts, constructive challenge is often precisely what is needed. Systems deployed at scale will inevitably interact with individuals experiencing paranoia, suicidal ideation, trauma-related vigilance, and severe mood episodes. The design choice between friction and affirmation has psychological consequences. The lack of guardrails is a central theme running throughout litigation postulating negligent design, failure to warn, inadequate risk mitigation, and the foreseeable harm in susceptible users.

If AI is to coexist responsibly with psychiatric care, it must be built with a clearer understanding of vulnerability. Guardrails cannot be limited to crisis hotlines and disclaimers. They must include calibrated responses that distinguish between emotional validation and epistemic endorsement.

In the era of conversational AI, folie à deux no longer requires two human minds. It requires one vulnerable mind and one endlessly accommodating system. While AI does not share delusions in the human sense, it can participate in belief formation. For physicians, especially psychiatrists, the challenge is to restore reflective space. To slow down certainty. To differentiate feeling understood from being correct. We must recognize when the algorithm has become an accomplice and to reintroduce dialogue and disciplined empathy that define the relationship between patients and their doctors.

Arthur Lazarus, MD, MBA, is a former Doximity Fellow, a member of the editorial board of the American Association for Physician Leadership, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia. He is the author of several books on narrative medicine and the fictional series, "Real Medicine, Unreal Stories." His latest book is "Practicing in the Age of AI: Medicine, Meaning, and Machines" (American Association for Physician Leadership, in press).

https://www.medpagetoday.com/opinion/second-opinions/120736

'KFF: Urgent Care Clinics Move to Fill Abortion Care Gaps in Rural Areas'

 Providing abortions was the last thing Shawn Brown thought she'd be doing when she opened an urgent care clinic in this remote town in Michigan's Upper Peninsula.

But she also wasn't expecting the Planned Parenthood in Marquette to shut down last spring. Roughly 1,100 patients relied on that clinic each year for cancer screenings, intrauterine device insertions, and medication abortions. Now the area has no other in-person resource for abortions. "It's a 500-mile stretch of no access," Brown said.

So the doctor, who describes herself as "individually pro-life," added medication abortions to Marquette Medical Urgent Care's already busy practice, which treats a steady flow of kids with the flu, college students with migraines, and tourists with skiing injuries.

At least 38 abortion clinics shut down last year in states where they're still legal, according to data collected by I Need an A, a project supported by a number of nonprofits that helps people find abortion options. Even states that recently passed constitutional amendments protecting abortion rights, such as Michigan, have had clinics close since the U.S. Supreme Court overturned Roe v. Wade in 2022. And as rural hospitals shutter labor and delivery units, patients are losing access to pregnancy care. "You cannot have a high-risk pregnancy up here," Brown said. "It's a scary place."

Now communities are coming up with alternatives, such as Brown's urgent care.

The idea that urgent cares "could be an untapped solution to closures for abortion clinics across the country is really exciting," said Kimi Chernoby, MD, the chief operating and legal officer at FemInEM, a national nonprofit that works to improve professional training and patient outcomes for women in emergency medicine.

One patient at the Marquette urgent care on a recent day was a woman whom KFF Health News agreed to identify by only her first initial, "A," to protect her medical privacy. She drove more than an hour on snowy backroads while her kids were in day care to get to her appointment.

Her youngest is still a baby, A said, and she got pregnant again while taking the progestin-only birth control pill, which is less likely to interfere with breast milk production but slightly less effective than the regular pill.

"Financials, housing, vehicles -- it's a lot," she said. And another baby is "just not something that we could really do even at this time."

She said she was making the long round trip because receiving abortion care in an office felt more secure than being treated by "someone that I've never met, or receiving meds that were just shipped to me."

Face-to-Face Care

In one of the urgent care's exam rooms, A sat in a chair against the wall, waiting quietly for the doctor. Viktoria Koskenoja, MD, an emergency medicine physician, knocked on the door and then greeted her warmly, pulling up a stool across from her.

"Are you confident in your decision that you want to go ahead? Or do you want to talk about options?" she said.

"No, I'm pretty set on it," A said.

Koskenoja previously worked at Planned Parenthood. When she learned its Marquette clinic was closing, she started crying and making calls. She recalled asking everyone she knew in healthcare in Marquette: "What are we going to do?"

One of her first calls was to Brown, a friend and fellow emergency medicine doctor. Their families harvest maple syrup together each spring.

In the wake of the Planned Parenthood closure, Koskenoja convened a community meeting downtown at the Women's Federated Clubhouse, an 1880s-era building where guests sip from gold-rimmed china teacups on lace tablecloths. The goal: brainstorm new ways to provide abortion access in the Upper Peninsula.

Planned Parenthood of Michigan officials said that growing financial challenges and the Trump administration's cuts to funding, including for the public insurance program Medicaid, had prompted the closures of some brick-and-mortar clinics in the state.

Plus, the availability of pills by mail exploded after the 2022 Dobbs v. Jackson Women's Health Organization decision overturned Roe. As abortion became illegal in many states, telehealth abortions went from 5% of all abortions provided to 25% by the end of 2024, according to #WeCount, a national reporting project that tracks shifts in abortion volume.

Planned Parenthood of Michigan's telehealth appointments increased 13% for patients in the Upper Peninsula after the Marquette location closed, said Paula Thornton Greear, president and CEO of Planned Parenthood in the state.

All the abortion patients Koskenoja sees at the urgent care have one thing in common: They want to talk to someone in person.

"I had a patient order the pills online and then get scared to use them because they felt like they were going to screw it up, or they weren't sure they could rely on the pills," she said. "So they literally came in here with the pills in their hand."

Others have medical complications or need an ultrasound to determine how far along they are with the pregnancy.

"It annoys me that telehealth is considered an acceptable thing in rural areas," Koskenoja said. "As though we're not the human beings that like talking to human beings and looking someone in the eye, especially when something serious is going on."

The Urgent Care Option

The options presented at that community clubhouse meeting were limited. The few family medicine doctors and ob/gyns in the area were either already putting patients on months-long waitlists or were too "rightward leaning," Brown said.

But urgent cares are designed to fill gaps in the system, she said, ready to take walk-ins who aren't already patients.

Brown knew from her years in the emergency room that medication abortions aren't that complicated. The professional guidelines for first-trimester medication abortions and miscarriages are essentially the same: one dose of mifepristone, followed by misoprostol after 24 to 48 hours.

"Clinically, I was never worried about it," she said.

The biggest hurdle was getting medical malpractice insurance, Brown said. At first, insurers balked, demanding "onerous and unrealistic" documentation and additional training, she said. Then they quoted a $60,000 annual premium for medication abortions -- about three times the cost of insuring the entire urgent care. Ultimately, Brown said, the urgent care's broker pushed back, providing data that medication abortions didn't add "significant liability."

The company agreed to a premium of about $6,000 per year, she said.

The community pitched in, too. A local donor covered an ultrasound machine. And supporters started a nonprofit to help pay for the costs of the medication and additional staffing, bringing the price for patients down from about $450 to an average of about $225, based on a sliding scale.

Word spread quickly once Marquette Medical began offering medication abortions, Brown said. Now the office provides as many as four per week, with patients traveling from as far away as Louisiana. The clinic is on track to match the volume of abortion patients treated at the local Planned Parenthood office before its closure, Brown said.

As pills by mail become the next major target for abortion opponents, Chernoby said, it will be critical to offer more care in more brick-and-mortar places. Brown said the Marquette clinic has already fielded questions from a large academic medical center that plans to start providing medication abortion at its own urgent cares later this year.

"It's a wonderful idea, but it's potentially got major pitfalls," said David Cohen, a professor at the Drexel University Kline School of Law who studies abortion access.

Urgent cares that provide medication abortion would have to abide by state-specific laws -- some mandate 24-hour waiting periods or facility structural requirements -- and federal regulations, such as the FDA's requirement that mifepristone prescribers be certified by the drug's distributors and obtain signed patient agreements.

If abortion access isn't a core part of a health organization's mission, "do you want to be on that list? I don't know if you do," Cohen said. "There's just a very particular regulatory environment" around abortion.

Making a Choice

In the exam room, Koskenoja listened as A talked about why she decided to seek an abortion. She has four kids at home, including the baby.

"You OK if we do an ultrasound, just confirm how far along you are, make sure it's not an ectopic pregnancy?" Koskenoja asked.

"Yeah," A said.

Koskenoja noted A's reaction to the question. "OK. You're making a face?"

"Yeah, I just don't -- yeah, it's fine. I just don't want to see it."

"Oh, you don't have to see it," Koskenoja said.

"I just don't want to hear a heartbeat or anything like that," A said.

"Definitely not," Koskenoja said.

After the ultrasound, Koskenoja stepped out into the hall to give A time to call her partner.

When A said she was ready, Koskenoja stepped in and asked her how she was feeling. A had made up her mind. She said that her partner would be supportive of whatever she decided and that she didn't want to have another baby right now.

"As much as I know this baby would be loved no matter what, it's just not a good time," A said quietly, her hands in her lap.

"Most people who get abortions love babies," Koskenoja said. And you can still have more in the future, she assured A.

This kicked off a long conversation about the mental load of parenting and the pros and cons of various birth control options. A said she wanted to get her tubes tied, but Koskenoja suggested her partner consider a vasectomy instead. It's a much less invasive procedure, she said. "You've had a lot of kids. I feel like it could be his turn to take some responsibility."

Koskenoja handed her a small, handsewn "comfort bag" that all medication abortion patients receive. It was filled with the pills, reminders about when to take them, a handwritten note of support from local community members, pain meds, comfortable socks, and a heating pad.

"Call us if you need anything," she told A. "Any questions?"

"No," A said.

"OK. Good luck," Koskenoja said before A walked out past the waiting room, filled with sick babies and other patients, to drive back to her kids.

https://www.medpagetoday.com/obgyn/abortion/120717

Iran warning on Trump’s Strait of Hormuz blockade: ‘Forceful response’

 Iran warned Sunday that military vessels approaching the Strait of Hormuz would be a violation of the fragile cease-fire and face a “strong and forceful response” — following President Trump’s announcement of a blockade on the critical oil chokepoint.

Trump announced plans earlier Sunday to stop “any and all Ships trying to enter, or leave” the waterway until there’s a point where all oil is allowed to go in and out without obstruction from Iran.

Iran’s Islamic Revolutionary Guard Corps Navy hit back, insisting it has “full control” of the Strait and that the waterway remains open for non-military vessels.

Iran’s navy warned Sunday that military vessels approaching the Strait of Hormuz will face a “strong and forceful response,”AFP via Getty Images

“Contrary to the false claims of certain enemy officials, the Strait of Hormuz is open for the passage of non-military vessels under smart control and management, in accordance with specific regulations,” the naval forces said in a statement, according to two semi-official Iranian news agencies.

The IRGC warned that any approach by military vessels toward the Strait would be treated as a violation of a cease-fire agreement.

Trump claimed that the cease-fire deal last week meant that Iran would allow the Strait of Hormuz, where over a fifth of the world’s seaborne oil supplies flow through annually, to be reopened.

A woman walks past a giant billboard reading ‘The Strait of Hormuz remains closed’ at the Revolution Square in Tehran on April 12, 2026.AFP via Getty Images

But Iran has been accused of attempting to charge tolls on vessels going through and claimed that it lost track of the mines it laid down, scaring off ships from traversing the beleaguered waterway.

Despite Iran’s threats to view the deployment of a military vessel through the Strait as a violation of the cease-fire, the US claims that two American Navy destroyers went through it Saturday and took down an Iranian drone.

https://nypost.com/2026/04/12/world-news/iran-issues-dire-warning-about-president-trumps-strait-of-hormuz-blockade/