Lead contamination in the drinking water in Newark, N.J., is not a new problem, but the city’s fleeting solution has become newly problematic.

Officials in Newark, the state’s largest city, which supplies water to some 280,000 people, began to hand out bottled water Monday.

That’s because the U.S. Environmental Protection Agency has concerns about water filters that the city distributed to residents.

Last fall, Newark gave out more than 40,000 water filters, even going door to door to reach families with lead service lines. The toxin is believed to have leached into drinking water through the old pipes between water treatment plants and people’s homes. Free filters and cartridges would remove 99% of lead, the city of Newark said.

But recent test results introduced an element of doubt about that claim. A regional administrator at the EPA sent a letter Friday to city officials, saying tests on two homes suggested the filters “may not be reliably effective.” Samples showed the filtered drinking water had lead levels exceeding 15 parts per billion, which is the federal and state standard, EPA regional administrator Peter Lopez said.

City leaders acknowledged the problem in the days that followed.

Gov. Phil Murphy and Mayor Ras Baraka, both Democrats, said in a joint statement that they were prepared to do “everything the City needs,” including doling out free water bottles.

They added that the city and state will need assistance from the federal government to provide and distribute the bottles.

In January, Baraka urged President Trump to help protect Newark’s fraught water infrastructure systems instead of funding a wall at the U.S. Southern border to deter migrants. “It will cost an estimated $70 million to replace the lead service lines in Newark,” Baraka said in a letter.

A spokesperson for Sen. Cory Booker, a former mayor of Newark and presidential candidate, told NPR that the senator had made efforts to address New Jersey’s water problem. “We’ll be sending a letter to the [EPA]” later on Tuesday with other federal lawmakers in New Jersey, “urging the EPA to help the city and state with distributing bottled water to its residents,” spokesperson Kristin Lynch said.

Booker also introduced the Water Infrastructure Funding Transfer Bill in May. He said the measure would give states flexibility to fund infrastructure projects. That bill’s passage was blocked in Congress, Lynch said.

Newark resident Emmett Coleman told USA Today that he spent an hour on Monday waiting for two cases of bottled water. “In the senior building, it’s bad,” he said. “All of us are sick or have problems, and we can’t drink the water. And the filters aren’t working.”

The distribution scene would have looked familiar to residents in Flint, Mich., who suffered from years of contaminated drinking water and subsisted on bottled water. And like Flint, Newark has a high poverty rate — about 28%, compared with the national rate of 12.3% in 2017, according to the Census Bureau.

About 15,000 homes in Newark had lead service lines that brought contaminated water to their residences, the city said in a statement. It advised residents to take precautions, including getting children’s blood tested for lead exposure.

The city will continue to test both the filters and filtered water.

The Natural Resources Defense Council and Newark Education Workers Caucus sued Newark and New Jersey state officials last year, accusing them of violating the federal Safe Drinking Water Act. “If it takes filing a lawsuit to end violations of federal drinking water law, we’ll do it,” Claire Woods, an attorney with NRDC, said at the time. That lawsuit is pending.

Authorities say there is no safe level of lead exposure. Pregnant women and children are the most vulnerable groups, with dangers that include fertility problems, damage to organs and cognitive dysfunction.

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There’s a summer camp for kids with disabilities in Nashville that does things a little differently. Instead of accommodating the campers’ physical challenges, therapists make life a bit tougher, in hopes of ultimately strengthening the kids’ ability to navigate the world.

Priceless Garinger’s left arm is wrapped from shoulder to fingertips in a neon pink cast on the day I visit. The left is actually the 12-year-old’s strong hand. It’s her other arm and hand that’s been the problem since she was born with cerebral palsy. She can move her right arm but has difficulty grasping anything.

“Right there, where you bend your arm, it itches right there,” she says, using a plastic spoon to scratch her elbow, which is out of reach.

This day camp is organized by Vanderbilt Children’s Hospital. Some campers, like Priceless, have cerebral palsy; others have had a brain tumor removed, or had a stroke. All of them have a weak side of the body they rarely use. At High Five Constraint Camp the children are forced to try to strengthen that weak side.

“Yeah, there it is,” Priceless says as she bumps bare arms with a fellow camper — an improvised fist bump.

This kind of rehab is known as constraint-induced movement therapy. Similar camps are run by children’s hospitals all around the U.S. during the summer, based on research by Edward Taub at the University of Alabama at Birmingham. He hypothesized years ago that the affected limbs suffer from “learned nonuse.”

Priceless takes her turn on the indoor obstacle course at the hospital’s pediatric rehab facility, located at a Vanderbilt satellite campus on Nashville’s outskirts. She rides a modified zipline, wrapping her long legs around the swinging seat — swooping along and then dropping into a pit of overstuffed pillows.

The occupational therapists prompt her to climb out. They cheer her on but don’t immediately help. The struggle is the point.

Priceless finds her way out, and next plops down on a scooter. She grunts as she tries to propel herself with a hand that she can barely control.

“I’m not going anywhere,” she says.

Her therapist gives her a little boost toward the finish line, where Priceless hits a buzzer that sounds an alarm and draws cheers from the other campers.

Constraint-induced therapy

The restrictive rehab techniques are increasingly used with kids who have cerebral palsy, though there hasn’t been much research showing the approach is all that much better than traditional physical therapy. And some kids become overly frustrated or even refuse to cooperate.

To outsiders, the strategy can seem mean.

“If the families have never heard of it before, it’s kind of like, ‘What? You’re going to cast their good arm and take away their really functional hand?’ ” says occupational therapist Stephanie Frazer.

This particular day camp started a decade ago as part of a research project at Vanderbilt University. When the study concluded, the camp shut down. But Frazer revived it in recent years because she believes the approach, and the setting, are effective.

“Whenever we’re casting that good arm, the brain is like, ‘I have this other arm here.’ And they start using it more and it starts creating pathways,” she says. “They actually make a lot of progress in a short amount of time.”

The kids’ temporary casts end in a mitten shape to minimize any wiggle room and attempts to rely on that stronger hand while at camp.

Blake Farmer/Nashville Public Radio

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Blake Farmer/Nashville Public Radio

Even snacktime can be turned into a therapeutic experience. Playing with food is required at this camp. The kids take pretzels and stab them into blocks of cheese.

Some blow bubbles in their juice, partly out of frustration. Some resort to using the arm that’s in a cast to feed themselves.

Seeking independence

This is the third summer of camp for Priceless, who wasn’t exactly enthusiastic when she started. But she’s beginning to see how helpful it would be to be able to rely on both hands to do things like manipulate a remote control.

“I want to play with my iPad and watch TV,” she says.

The parents of the campers are even more motivated, because they understand how the use of two hands could make independence in adulthood much more feasible for their children.

“She talks about wanting to drive,” says Laura Garinger, Priceless’ mom.

From past experience, Garinger says she suspects that for the first few months after this camp session, Priceless will use her weak hand more often. But in past summers she has eventually reverted to relying on her strong side.

Still, Garinger says, she has witnessed lots of other, permanent successes.

Garinger, who is a special education teacher, met Priceless when the little girl was 3 years old; she adopted Priceless two years later. The preschooler needed to use a walker at the time. Now she walks on her own.

Being able to rely on both hands would go a long way toward helping Priceless achieve her dreams, her mom says.

“She hopes to be a police officer, so the sky’s the limit. We’ll see,” Garinger says, pausing as her voice shakes with emotion. “I mean, it’s probably not realistic, but I always tell her she can do what she wants when she grows up.”

Garinger says the first step for Priceless is strengthening her arm enough to give a high-five — and a two-arm hug.

This story is part of NPR’s reporting partnership with Nashville Public Radio and Kaiser Health News.

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Five years after Congress passed a law to reduce unnecessary MRIs, CT scans and other expensive diagnostic imaging tests that could harm patients and waste money, federal officials have yet to implement it.

The law requires that doctors consult clinical guidelines set by the medical industry before Medicare will pay for many common medical scans for enrollees. Health care providers who go way beyond clinical guidelines in ordering these scans (the 5 percent who order the most tests that are inappropriate) will, under the law, be required after that to get prior approval from Medicare for their diagnostic imaging.

But after physicians argued the provision would interfere with their practices, the Trump administration delayed putting the 2014 law in place until January 2020 — two years later than originally planned.

And even then, the Centers for Medicare & Medicaid Services has slated next year as a “testing” period, which means even if a physician doesn’t check the guidelines, Medicare will still pay for the scan. CMS also said it won’t decide until 2022 or 2023 when exactly physician penalties will begin.

Critics worry the delays come at a steep cost: Medicare is continuing to pay for millions of unnecessary exams, and patients are being subjected to radiation for no medical benefit.

A Harvard study published in 2011 in the Journal of Urology found “widespread overuse” of imaging tests for men on Medicare who were at low risk of getting prostate cancer. And a University of Washington study in the Journal of the American College of Radiology that reviewed 459 CT and MRI exams at a large academic medical center found 26% of the tests were inappropriate.

“These delays mean that many more inappropriate imaging procedures will be performed, wasting financial resources and subjecting patients to services they do not need,” says Gary Young, director of the Northeastern University Center for Health Policy and Healthcare Research in Boston. “If this program were implemented stringently, you would certainly reduce inappropriate imaging to some degree.”

Doctors order unnecessary tests for a variety of reasons: to seize a potential financial advantage for them or their health system, to ease fears of malpractice suits or to appease patients who insist on the tests.

The law applies to doctors treating patients who are enrolled in the traditional fee-for-service Medicare system. Health insurers, including those that operate the private Medicare Advantage plans, have for many years refused to pay for the exams unless doctors get authorization from them beforehand. That process can take days or weeks, which irks physicians and patients.

CMS Administrator Seema Verma has sought to reduce administrative burdens on doctors with her “patients over paperwork” initiative.

CMS would not make Verma or other officials available for an interview for this story and answered questions only by email.

A spokeswoman says CMS has no idea how many unnecessary imaging tests are ordered for Medicare beneficiaries.

“CMS expects to learn more about the prevalence of imaging orders identified as ‘not appropriate’ under this program when we begin to identify outlier ordering professionals,” she says.

“It takes four clicks on a computer”

An influential congressional advisory board in 2011 cited the rapid growth of MRIs, CT scans and other imaging and recommended requiring doctors who order more tests than their peers to be forced to get authorization from Medicare before sending patients for such exams. In the 2014 law, Congress tried to soften that recommendation’s effect by asking doctors billing Medicare to follow protocols to confirm that imaging would be appropriate for the patient.

Studies show a growing number of health systems have used clinical guidelines to better manage imaging services. The University of Virginia Health System found that unnecessary testing fell by between 5% and 11% after implementing such recommendations.

Virginia Mason Health System in Seattle in 2011 set up a system requiring its physicians — most of whom are on salary — to consult imaging guidelines. It would deny claims for any tests that did not meet appropriate criteria, except in rare circumstances. A study found the intervention led to a 23% drop in MRIs for lower back issues and headaches.

Dr. Craig Blackmore, a radiologist at Virginia Mason, says he worries that unlike the efforts at his hospital, many doctors could be confused by the Medicare program because they have not received proper training about the guidelines.

“My fear is that it will be a huge disruption in workflow and show no benefit,” he says.

In 2014, AtlantiCare, a large New Jersey hospital system, began grading physicians on whether they consult its guidelines.

“Some doctors see this tool as additional work, but it takes four clicks on a computer — or less than a minute,” says Ernesto Cerdena, director of radiology services at AtlantiCare.

Not all Medicare imaging tests will be subject to the requirements. Emergency patients are exempt, as well as patients admitted to hospitals. CMS has identified some of the most common conditions for which doctors will have to consult guidelines. Those include heart disease, headache and pain in the lower back, neck or shoulders.

Robert Tennant, director of health information technology for the Medical Group Management Association, which represents large physician groups, says the law will unfairly affect all doctors merely to identify the few who order inappropriately.

“For the most part, doctors are well trained and know exactly what tests to perform,” Tennant says.

The association is one of several medical groups pushing Congress to repeal the provision.

American College of Radiology’s role

The law required the federal government to designate health societies or health systems to develop guidelines and companies that would sell software to embed that guidance into doctors’ electronic health record systems.

Among the leaders in that effort is the American College of Radiology, which lobbied for the 2014 law and has been issuing imaging guidelines since the 1990s. It is one of about 20 medical organizations and health systems certified by CMS to publish separate guidelines for doctors.

The college wanted “to get ahead of the train and come up with a policy that was preferable to prior authorization,” says Cynthia Moran, an executive vice president of the radiology group. About 2,000 hospitals use the college’s licensed guidelines — more than any others, she says. And the college profits from that use.

Moran says the licensing money helps the college mitigate the costs of developing the guidelines, which must be updated regularly, based on new research. She says the college gives away the guidelines to individual doctors upon request and sells them only to large institutions, although she notes they are not as easy to access that way, compared with being embedded in a doctor’s medical records.

Kaiser Health News a nonprofit, editorially independent program of the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.

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