One shred of solace that surfaced as hurricanes and tropical storms pummeled Texas, Florida and Puerto Rico last fall was the opportunity to see drones realize some of their life-saving potential.

During those disasters unmanned aircraft surveyed wrecked roads, bridges and rail lines. They spotted oil and gas leaks. They inspected damaged cell towers that had left thousands unable to call for help. “Drones became a literal lifeline,” former Federal Aviation Administration chief Michael Huerta told the agency’s drone advisory committee in November.

The drones used needed a special exemption from a set of FAA rules, known as Part 107, that normally require small drones to fly below 400 feet, stay within the operator’s visual line of sight and avoid populated areas.

These regulations make it hard for commercial drones to operate in the United States. But last October the Department of Transportation took a big step: It invited state and local governments to partner with universities and companies on tests to speed the integration of drones into the national airspace. The FAA is reviewing 149 proposals and plans to choose five to 10 by mid-May.

The proposals cover a wide range of applications. Many of them are health-related. “I am confident that one-half or more of all the applicants have put some element of medical support in their proposal,” says John Walker, a Lancaster, Penn.-based aerospace consultant who spent 32 years at the FAA before co-founding the Padina Group, Inc in 2006.

Walker believes early public acceptance of drone delivery networks in urban areas will revolve around hospitals. And once drones can safely and reliably carry blood and medical supplies, that will pave the way to other kinds of drone deliveries. “That linear network where drones can operate between hospitals … would also have Amazon and anyone else that could meet the requirements to operate,” Walker says.

Several companies have approached governments in developing countries about performing medical deliveries in areas with great need, poor roads and less crowded skies.

In late 2016 Zipline, a San Francisco Bay Area-based robotics startup, set up distribution centers in Rwanda, where its drones had made more than 1400 flights carrying on-demand blood and emergency supplies over 62,000 miles as of last fall. This year the company will expand its medical delivery operations by launching a second base in Rwanda and new service in a larger neighboring country, Tanzania.

Last October Swiss Post launched a medical transport network in Lugano, Switzerland, using drones made by another Bay Area company, Matternet. So far the drones have made 350 deliveries, about 5 to 15 per day. Other groups have also brought aircraft abroad to attempt health-related deliveries, but those demo flights have not become sustained operations.

Such efforts face tougher hurdles here in the U.S. where regulations focus on safely integrating drones into already congested national airspace. “We haven’t seen [the FAA] be interested in a one-off approach,” says Susan Roberts, co-founder of AiRXOS, a General Electric subsidiary focused on drone infrastructure technologies. “It doesn’t do anybody any good for a delivery company to be able to fly from two specific points if they can’t then scale that over and over again.”

Beyond blood and medical supply deliveries, drones could transform another key component of healthcare — lab tests. Timely test results help doctors diagnose infections and reduce guesswork in prescribing medications. Some of those decisions have life-or-death implications. For example, newborn babies turn yellow from jaundice as their bodies make bilirubin, a byproduct formed during normal breakdown of red blood cells. But “very high bilirubin can be toxic to babies,” says Dr. Geoff Baird, a clinical pathologist at the University of Washington in Seattle.

Of the millions of blood samples, urine specimens and swabs his team processes each year, most reach central lab facilities by car. “We have cars going seven days a week, many times a day, up and down the state of Washington on freeways, across the passes, in the mountains,” Baird says. The university also does testing for out-of-state hospitals and several clinics in rural communities on the San Juan Islands off the northwest coast of Washington. Getting lab samples from the islands down to Seattle hospitals for testing requires multiple stops by car, plane and ferry — a journey of about 100 miles that often takes more than 24 hours, even longer on weekends.

But samples carried over the Puget Sound on a drone from the San Juan Islands could reach the main lab in Seattle in 90 minutes, Baird says. That’s why the university was eager to put in a bid for the FAA program.

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A temperature-controlled container was designed by Johns Hopkins researchers to transport specimens, like these test tubes containing blood samples.

Johns Hopkins School of Medicine

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Johns Hopkins School of Medicine

The proposed medical deliveries are part of a larger application submitted by Washington’s Department of Transportation, which includes other companies such as Amazon and T-Mobile. If selected, Baird says the San Juan efforts will use drones developed at Tuscon, Ariz.-based Latitude Engineering. Latitude makes the military-grade aircraft that Johns Hopkins researchers used to set a distance record carrying refrigerated blood samples ~160 miles in a 3-hour flight across the desert.

North Carolina’s Department of Transportation also applied to the FAA program wanting to use drones for medical deliveries. Zipline and Matternet are on that application as well as several other undisclosed proposals. Matternet is also partnering with the city of Palo Alto on a proposal to shuttle blood to Stanford hospitals. Flirtey, a drone manufacturer in Reno, Nev., is focusing on using its aircraft for last-mile delivery of defibrillators — devices the company thinks could save hundreds of thousands of lives in America each year, by increasing the chance of survival from out-of-hospital cardiac arrest.

Ultimately, though, what makes or breaks a proposal isn’t likely the whiz-bang drones but rather the underlying infrastructure that ensures they can fly safely alongside commercial jets, helicopters, balloons and everything else in the sky.

Toward that end, at a drone symposium held earlier this week in Baltimore, the FAA stressed its interest in “sense and avoid” technologies to prevent drone crashes, and systems that allow drones to be identified and tracked remotely. GE’s projects cover both areas. “No one company is going to solve everything. We’re taking a holistic approach,” Roberts says. “We need to help the medical deliveries, we need to help the inspectors, we need to help people who are just taking pictures of houses.”

The United Nations Children’s Fund is working to foster this all-inclusive spirit at the global level. Last summer, UNICEF worked with local governments in the African country of Malawi to launch a drone corridor for companies, universities and nonprofits to fly test missions there.

More recently, UNICEF invited groups to transport vaccines in Vanuatu, the South Pacific nation made up of roughly 80 islands east of Australia. The drone corridors run on a barter system, says Chris Fabian, who leads UNICEF’s venture capital arm. “If you come and use our time, create something that’s open-source and useful for everyone else.”

Esther Landhuis is a freelance science journalist in the San Francisco Bay Area. Follow her on Twitter @elandhuis.

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No, you can’t.

That’s what federal officials told Idaho regulators and the state’s governor late Thursday regarding the state’s plan to allow insurers to sell health plans that fall short of the Affordable Care Act’s requirements.

But the letter from the Trump administration did offer an alternative: Tweak your plan a bit to make them qualify as “short-term” policies. These alternatives, which offer coverage for a limited time, are exempted from ACA rules — including the rule that bars insurers from rejecting people who have pre-existing medical conditions.

“On the one hand, they’re saying they’re going to enforce the ACA,” says Sarah Lueck, a senior policy analyst at the Center on Budget and Policy Priorities. But, Lueck adds, the Health and Human Services Department also seems to say, ” ‘if you want to roll back protections for people with pre-existing conditions, we have some ideas for you.’ And that concerns me.”

Idaho’s approach, announced in January, would have allowed insurers to offer “state-based” insurance plans that did not include some of the ACA’s consumer protections. A few weeks later, Idaho Blue Cross jumped in with five “Freedom Blue” state-based plans it hoped to sell.

Regulators in other states were watching the Idaho situation. Its move was viewed either as a brazen effort to flout federal law or an innovative attempt to stabilize the market. Regardless, Idaho’s action meant the Trump administration had to take a position: Enforce the ACA or look away.

Here are four key takeaways from the administration’s response to Idaho, and how the ruling may play elsewhere.

States and insurance carriers can’t ignore federal law

Although Thursday’s letter from Seema Verma, head of the federal Centers for Medicare & Medicaid Services, commended Idaho’s effort to “address the damage” caused by the ACA, it said that, as proposed, the state-based plans would violate at least eight of the federal health law’s provisions. For example, the ACA forbids insurers from charging sick people more for a policy than it charges those who are considered healthy; it bans the establishment of annual or lifetime coverage caps; and it won’t allow insurers to reject applicants who have pre-existing conditions.

Verma’s letter noted that if plans that don’t meet ACA standards were sold in Idaho, insurance carriers might face significant financial penalties. Health policy specialists say they would be surprised if insurers would want to take that risk.

“It’s one thing for the state to take on the CMS, but quite another for carriers,” says Jan Dubauskas, general counsel for the IHC Group, which sells short-term health insurance nationally. “When I heard that, I thought, ‘This is the end for state-based plans.’ “

But Idaho Gov. Butch Otter, a Republican, has been upbeat, saying the letter from Verma “was not a rejection of our approach,” but “an invitation … to continue discussing … what can and cannot be included in state-based plans.”

Late Friday, Idaho Blue Cross issued a statement expressing disappointment in the CMS decision, but also echoing Otter’s willingness to move forward.

The timetable going forward is not immediately clear, although both federal regulators and state officials say they are willing to talk about alternatives to Idaho’s original proposal. Following Verma’s suggestion to get new short-term plans on the market would also require Idaho’s insurers to consider their options, modify the plans and come up with new premium rates — all of which takes time.

Short-term plans get another boost

Dubauskas and others say the Idaho decision could increase interest in short-term plans.

Such policies have been sold for years, meant as a stopgap for people between jobs. They are less expensive than ACA plans, mainly because they are allowed to reject people who have health conditions (or exclude coverage for such conditions) and have other limitations.

Most short-term plans don’t cover treatment for substance abuse or mental health issues; few cover maternity care and some don’t include prescription drug coverage. They generally can’t be renewed — meaning consumers must reapply and answer medical questions each time their policies expire.

The Obama administration, fearing that short-term plans would suck relatively healthy people out of the ACA market, limited such policies to 90-day terms. The Trump administration, however, has proposed allowing short-term plans to last for up to a year. These final rules aren’t expected for at least another two months.

Ironically, Idaho Insurance Director Dean Cameron had in January promoted the more robust “state-based” plans — like those the Blues insurer wanted to sell in Idaho— as an alternative to short-term coverage.

After getting the CMS letter, Cameron told the Idaho Statesman newspaper that short-term plans might be easier for the Trump administration to handle legally, but could cause consumers more problems than what Idaho had proposed.

Critics fear that consumers will buy such plans without understanding their limitations.

“They might think it’s health insurance like they’re used to,” Lueck says. “But it’s really not. It’s really very bare-bones.”

State reactions will vary widely, creating different rules around the country

Even if the Trump administration’s proposal to extend short-term coverage to a full year is finalized, states can set stricter rules.

A handful of states already do.

New York and New Jersey require many of the same rules as the ACA for policies sold in their states. But insurers won’t sell short-term plans there.

Four states — Arizona, Michigan, Minnesota and Oregon — limit the length of short-term plans sold in their states to 185 days, according to a survey by the Commonwealth Fund and researchers at Georgetown University.

“A small group of largely blue states have some regulation [of short-term plans], but not very many,” says Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. “It’s possible that if this rule is finalized we will see more states start to step up and regulate short-term markets.”

Conversely, lawmakers in other states may promote short-term coverage as a lower-cost alternative to the ACA — although people with pre-existing conditions may not be able to buy such plans.

“Politically, short-term plans have some appeal because lawmakers can say now there’s a cheaper option out there,” Corlette notes.

The increased emphasis on short-term plans could increase premiums

Actuaries fear that short-term plans — or state-based plans like those rejected in Idaho — would drive up costs for people who remain in more comprehensive ACA coverage.

That’s because younger and healthier people might be tempted to drop their ACA coverage, leaving only those who are older, sicker and costlier in the remaining pool. That, in turn, drives up premiums — affecting millions of Americans who don’t receive subsidies and already struggle to pay for their health insurance.

But just how many people would jump to new, short-term coverage?

The Trump administration has estimated that about 100,000 to 200,000 people with existing ACA coverage would make the shift, while other specialists in health insurance suggest higher numbers.

Christopher Condeluci, a Washington, D.C., attorney who specializes in employee benefits and previously served as the tax and benefits counsel to the U.S. Senate Finance Committee, says it’s unclear which estimates are correct.

The real issue to keep in mind, Condeluci says, is that an increasing number of people who don’t get subsidies are already choosing to either forgo coverage or pick an alternative, such as a short-term plan.

“People are voting with their feet,” he said. “That cannot be overlooked.”

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente. You can follow KHN senior correspondent Julie Appleby on Twitter @Julie_Appleby.

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Last Saturday, while I was visiting Fatty’s Tattoos and Piercings, a college-aged woman in a hoodie walked in and asked for a tattoo, her first, right on the spot.

“I want a red-tailed hawk feather,” she told the artist on duty at the Washington, D.C., tattoo parlor.

He peppered her with questions: How big? What style? She alternated between a blank stare and a furrowed brow: “I … have a photo on my phone of the feather that I like, I could show you that?”

The artist rubbed his beard and told her he didn’t do realistic tattoos. Maybe they should set up an appointment for her sometime next week, with another artist, he offered. Between the lines, he seemed to say, “This will be permanent, so I don’t want to give you the wrong tattoo.”

But considering how many changes skin weathers — burns heal, scars fade and wrinkles set in — it’s sort of unbelievable that tattoos do stick around.

Recently, a group of French scientists looked into how that works, hoping to use the knowledge to improve tattoo removal.

So, first, of course, they gave some mice tattoos.

The mice didn’t get Mom tattoos on their tiny biceps. Instead, they got tail tats — three stripes of green ink — for researchers to study.

“The thing is, the mouse skin can be super fragile, much more fragile than human skin,” says Sandrine Henri, an immunologist at the Centre d’Immunologie Marseille-Luminy.

If you zoom way in on any tattoo, it’s really just a bunch of cells holding tight to ink particles. From the mice’s tail tattoos, Henri and her colleagues identified one type of cell that captured ink particles and stayed in place, the dermal macrophage.

The researchers thought they might be able to disrupt the tattoos by destroying the macrophages that had locked up the ink. So they engineered mice whose macrophages — and only those cells — would shrivel in the face of a specific toxin, and then injected that compound into these special, tattooed mice.

But it didn’t work.

The messed-up macrophages released their ink particles, but the color persisted. It turns out that new macrophages quickly took over the job of holding the tiny flecks of ink in place, and the mice kept their sporty green-striped tails.

But if it were possible, Henri says, to use an ointment, or a drug, to delaythose replacement macrophages,it might improve tattoo removal for mice — and humans. The researchers’ fingings appeared Tuesday in the Journal of Experimental Medicine.

To think about removing ink from human shoulders, rather than mouse tails, it helps to know how tattoos appear. In broad strokes, we understand this process, says Bruce Klitzman, a biomedical engineer at Duke who once worked on creating an erasable tattoo.

As a tattoo artist outlines a yin-yang symbol on someone’s shoulder, a solid needle loaded with ink pierces the tattoo-ee’s skin, or epidermis, and the needle’s exit lets pigment flow into a second layer of skin, the dermis, Klitzman says.

But any self-respecting immune system treats all visitors — including the ink particles meant to create a wolf’s face on your forearm — as unwelcome. So skin cells mount a multilevel attack on the ink particles.

First, the cells that weren’t hit by the tattoo needle block out guests, Klitzman says. Only a fraction of the ink an artist lays down actually makes it into the dermis, and this is also why new tattoos tend to leak ink as they heal.

Newly tattooed skin swells, the same way it would respond to any other wound, and blood and lymph ferry away the smallest bits of ink. For the remaining pigment particles, the next order of the immune system’s business is consuming the foreign invaders, to try to destroy them.

That’s where the macrophages, the cells Henri studied, come in. They’re specialized immune cells — their name means big eater in Greek — and their job is to slurp up interlopers, says Klitzman. “Macrophages can basically swallow many, many tattoo pigment particles, almost like a vacuum cleaner, just go along and suck up all those particles,” he says.

Usually, a macrophage digests the invaders it devours, using acid to rip its enemy apart. It’s a good strategy for killing bacteria and viruses, but not for tattoo pigments. Acid has little effect on the ink ingredients.

That means a macrophage that has gorged on ink has no way to finish its job. Eventually, the pigment-filled macrophages dial back their attack, content to contain the threat, even if they can’t completely neutralize it. “They just sit there like a full vacuum cleaner bag,” says Klitzman.

Another type of cell, called a fibroblast, is also known to take in some ink particles in human skin. Together, the macrophages and fibroblasts bind enough ink for the image of, say, a carrot or feather to appear on your calf.

Those cells and the pigment inside them can hang around for years. But all cells die eventually, which brought Henri and her team to their question: How do tattoos stay put as individual cells die?

Their work confirms that even when macrophages die and release their pigment particles, other macrophages quickly gobble up the ink, keeping it in place.

Even when the researchers grafted one mouse’s tail tattoo onto another mouse’s back, the second mouse’s own macrophages carried the skin graft’s tattoo. “The cells from the graft died and released the ink, and the host mouse’s cells captured it,” Henri says.

All of that, basically, underscores why tattoo removal is really, really difficult.

Laser removal is an option, says Jared Jagdeo, a dermatologist at University of California, Davis. Tuned to a wavelength specific to a tattoo’s colors, “lasers are able to break apart tattoo particles,” he says. The bursts of energy bust ink “from larger boulders into smaller rocks, and then into fine pebbles which then can be swept away by the lymphatic system.”

But laser removal is far from perfect. The process of blurring ink beyond recognition can take many sessions, spaced weeks apart, at a couple hundred dollars a visit.

Laser pulses irritate skin, and people show re-uptake of ink similar to Henri’s mice, Jagdeo says. He uses anti-inflammatory drugs to help tame that response, but it’s really difficult to remove all evidence of a tattoo. “Tattoos are at their baseline permanent, so if [someone gets] a tattoo they should plan on having it for a while,” he says.

Back at the tattoo shop, I don’t know if the woman with the red-tailed hawk feather ever managed to get her tattoo. Either way, I hope she’s happy with her decision. For now, tattoo removal is still a challenge.

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