The opioid epidemic has been fueled by soaring numbers of prescriptions written for pain medication. And often, those prescriptions are written by dentists.

“We’re in the pain business,” says Paul Moore, a dentist and pharmacologist at University of Pittsburgh School of Dental Medicine. “People come to see us when they’re in pain. Or after we’ve treated them, they leave in pain.”

Indeed, 12 percent of prescriptions for immediate-release opioids are written by dentists. In 2012, dentists ranked fourth among medical specialties for their opioid prescribing rates, according to data from QuintilesIMS. It has made dentists targets for people “doctor shopping” in order to get opioids.

“I have dentures,” said Shawn Bishop, who is recovering from an opioid addiction at Hope House, a treatment center in Boston. “I had went to get some legitimate work done. And I got some Percocet. I realized that by going to another dentist, I could get some more Percocets.”

Bishop, now 59, recounts the times he teamed up with others to play dentists for their opioid pills.

“He would look at our teeth or Mark’s teeth in particular,” Bishop said. “He would look at his teeth and say, ‘Yeah, we need to take this one, this one, and this one.’ And Mark will always say well, ‘I can’t do it today. Can we make an appointment for next week?’ And then the doctor will say, ‘Yeah, I need to write a prescription of Percocets.’ He kept bad teeth and toothaches just so he can do that, you know?”

For Bishop and his friends, the enterprise of getting opioid pain pills from dentists grew so routine that, he says, he became a professional at it.

“It was almost like they knew their part to play and we knew ours,” he said. “It was like actors in a little sketch there.”

Massachusetts has taken the lead in trying to reduce opioid prescription abuse. Last year, Gov. Charlie Baker’s office passed a law to prevent drug misuse. Dental schools in the state are also required to teach a set of core competencies that their students are required to meet before graduating. Students will have to demonstrate that they know how to consider nonopioid treatment options.

“At least at the medical school, the dental school, nursing school and pharmacy school level, you don’t graduate from those places without having studied this stuff and understanding both the positives and the negatives associated with using it,” Baker says. “In addition to that, making sure as a condition of relicensure, you’re getting everyone who is writing prescriptions as part of that process.”

Now, after decades of criticizing health care providers for undertreating pain and not prescribing enough pain medication, the pendulum is swinging back. Some dentists are getting back up to speed about alternatives to opioids.

“For most dental pains, the nonsteroidal anti-inflammatory drugs (NSAIDS) —that’s Advil, Aleve, Naproxen — those agents are every bit as effective as one Vicodin or one Percocet,” Moore says. “That’s been shown over and over and over again.”

This next generation of dentists is not only learning about how to prescribe opioids appropriately, but also about how to think about pain differently. At the Harvard School of Dental Medicine, students are learning how to approach pain, a world away from opioids.

“You can approach it from opioid therapy, you can approach it from different neuropathy drugs, you can approach from stretching exercises to meditation,” says Kellie Moore, a fourth-year dental student at Harvard. “And just kind of like, exhausting all the options.”

Leaning on different methods of pain treatment can yield mixed success, she says: what works with one patient might not work for another.

Dental students are also rethinking what the goal of treating pain is.

“On a scale of 0 to 10, with 10 being the worst, if we can get you to a 4 or 5, could you live with that and still function daily?” says Sam Lee, a fourth-year dental student. “If the answer is yes, then I think it’s important to the patient understand that that’s what we’re going to try to maintain as the new normal for them.”

David Keith, an oral surgeon at Massachusetts General Hospital, agrees.

“I think it does us a disservice, making us and the patients assume that we should a total smiley face and a zero level of pain,” he said. “That’s not the real world. So we take a tooth out. We do a dental implant. You’re going to be sore for a few days, but that doesn’t mean you can’t go to work.”

The changing definition of pain is part of a larger change in the profession of dentistry. And Jeff Shaefer, an orofacial pain specialist who teaches at the Harvard School of Dental Medicine, says the role of the dentist is changing as a direct result of the opioid crisis.

“Dentistry is part of the problem and I think that hurts — that we’ve been overprescribing medication,” he says. “Having a standard regimen to give every patient is not appropriate.”

Nationally, the profession of dentistry is starting to change as well. This summer, the Commission on Dental Accreditation, which sets accreditation standards for all dental schools, ordered all graduates to be competent in accessing for substance use disorder.

But currently practicing dentists may not be so eager for a change to their profession. Keith, who regularly gives lectures to dentists in the state, has heard their complaints.

“There is a reluctance to add that, as there is reluctance to check blood pressure or check a list of medication their patients are on because it adds time to the day,” he said.

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The Senate is again trying to tackle the politics of health care. Rather than going for sweeping changes, lawmakers are acting more like handymen this time, looking for tweaks and fixes that will make the system that’s already in place work better.

Sen. Lamar Alexander, R-Tenn., is leading the effort to stabilize the Affordable Care Act’s insurance markets for next year. He’s trying to get a bipartisan bill together in the next 10 days, he said Thursday. He’s working against the clock; insurance companies have only until Sept. 27 to commit to selling policies on the ACA exchanges, and to set their final prices for health plans.

It’s a big ask. And Alexander, who is chairman of the Senate’s Health, Education, Labor and Pensions Committee, was frank about what needed to happen.

“To get a Republican president and a Republican House and a Republican Senate just to vote for more money won’t happen in the next two or three weeks, unless there’s some restructuring,” he told a group of five governors who testified before his committee Thursday.

It was the second of four hearings the committee is holding while developing a new health bill.

All of the governors and most of the senators in the room agreed that the top priority was for Congress to appropriate money for what are called cost-sharing reductions. These reimburse insurance companies for discounts they’re required by law to give low-income customers.

President Trump has threatened to cut off the payments, and insurance companies have responded to that uncertainty by proposing higher premiums for next year.

Funding CSR’s is the easy part, Alexander said.

He was looking for tweaks that will appease conservative Republicans who for years have told their constituents that Obamacare is a failure. They would be hard-pressed to appropriate money to fund it without some substantive changes.

Alexander presented the dilemma to the governors as an opportunity to ask for specific changes they’d like to see happen fast.

“This train may move through the station, and this is the chance to change those things,” he said near the end of the hearing. “And so if you want to tell us exactly what those are, and we got it by the middle of next week, we could use it and it would help us get a result.”

The governors had plenty of ideas.

Massachusetts Governor Charlie Baker, a Republican, said establishing reinsurance plans — pools of money to help insurers when they face huge costs from severely ill patients — can cut premiums for everyone.

Alaska last year created a reinsurance program that almost immediately slowed down the inflation in health insurance premiums in that state, Lori Wing-Heier, the director of the Alaska’s Division of Insurance, told the committee in testimony Wednesday.

Democratic Sen. Maggie Hassan of New Hampshire thinks Washington should put up some of the money for such programs.

“I’d be making the argument that at least some of the seed money should be coming from the feds because the feds are going to save money,” she told the governors at Thursday’s hearing.

And the governors unanimously supported Alexander’s proposal to give states waivers that would allow them out of some of Obamacare’s regulations, and enable states to design their own health care systems.

“What we’re really focused on is, how do you make the bureaucracy easier so that you can get these various waivers that pretty much all of us agree offer not only cost savings but in many cases will improve the actual outcomes of health care delivered,” Gov. Steve Bullock, of Montana, told the committee.

Sen. Chris Murphy, D-Conn., said he was concerned that giving too much flexibility would diminish the quality of the insurance policies.

Gov. Bill Haslam, of Tennessee, took issue with that.

“There’s an assumption from the federal government, that’s a little offensive to be honest, that ‘you won’t care for the least of these unless we tell you exactly how to do it,’ ” he said.

The governors were divided on a suggestion by Alexander that catastrophic health plans — which have high deductibles and don’t cover routine health care — should be more widely available. Under the Affordable Care Act such policies are only available to people under age 30.

Alexander said expanding the role of such policies could help gain the support of conservative Republicans in the House and Senate who want consumers to have more and cheaper choices in their insurance plans.

Baker, of Massachusetts, said he opposed expanding such policies, but Gov. Gary Herbert of Utah said he liked the idea.

In the end, Alexander suggested the bill he’ll pursue will likely include funding for cost-sharing payments and a more flexible waiver program. But he says he’s open to ideas.

“The reason for the hearings is for me to learn and listen,” Alexander said.

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A popular federal-state program that provides health coverage to millions of children in lower- and middle-class families is up for renewal Sept. 30.

But with a deeply divided Congress, some health advocates fear that the Children’s Health Insurance Program could be in jeopardy or that conservative lawmakers will seek changes to limit the program’s reach. Other financial priorities this month include extending the nation’s debt ceiling, finding money for the Hurricane Harvey cleanup and keeping the government open.

“With all that is on Congress’ plate, I am very worried that a strong, wildly successful program with strong public support will get lost in the shuffle and force states to begin the process of winding down CHIP,” said Bruce Lesley, president of the advocacy group First Focus.

The program covers more than 9 million kids — typically from families not poor enough to qualify for Medicaid, the state-federal program that covers health care for people with low incomes.

Income eligibility levels for CHIP vary widely among states, though most set thresholds at or below 200 percent of the poverty level — about $49,000 for a family of four. Unlike Medicaid, CHIP is usually not free to participants. Enrolled families pay an average premium of about $127 a year.

Since CHIP’s enactment, the share of uninsured children in the U.S. fell from 13.9 percent in 1997 to 4.5 percent in 2015, according to the Medicaid and CHIP Payment and Access Commission.

The 20-year-old program has bipartisan support. One of its original sponsors is Sen. Orrin Hatch, R-Utah, chairman of the Finance Committee, which has scheduled a hearing on reauthorization Thursday.

It’s possible in the jam-packed legislative calendar this month that other health-related provisions could be attached to a CHIP reauthorization bill — such as Republican-sponsored changes to the Affordable Care Act. Those changes could keep the resulting bill from getting enough support from Democrats and some Republicans in the Senate for passage.

“It’s the only vehicle in health care policy other than the federal budget that’s going to be moving, so it’s likely extraneous items are likely to be added to it,” says Christopher Pope, a health policy researcher and senior fellow at the conservative Manhattan Institute.

Supporters of CHIP also worry about changes in eligibility for the program that could dampen enrollment.

The Affordable Care Act bumped up federal funding of CHIP by 23 percentage points and forbids states to restrict eligibility rules that were in place in 2010. Both of those requirements continue through September 2019.

The added funding means a dozen states have their entire CHIP programs paid for by the federal government. In the fiscal year that ended last September, states contributed less than $2 billion, compared with the federal government’s $13.6 billion contribution, according to the conservative Heritage Foundation. States should pay a higher share of the program’s costs, the foundation argues.

President Trump’s budget request this spring called for immediately eliminating the ACA bump in funding and ending the restriction on a state’s ability to curtail eligibility — often referred to as the “maintenance of effort” provision.

But that provision has kept CHIP stable at a time when the individual insurance market faces uncertainty, says Joan Alker, director of Georgetown University’s Center for Children and Families in Washington, D.C.

Advocates note that if children have to leave CHIP and move to marketplace coverage, their families may be forced to pay higher out-of-pocket costs for their kids’ health care.

Without the maintenance-of-effort requirement, advocates fear that states would be more likely to do what Arizona did during the last economic downturn: It froze enrollment from December 2009 until last June. The move was allowed because it took effect before the ACA’s restriction began in March 2010.

Meanwhile, Republicans are not united in their views of the maintenance-of-effort requirement. Some favor it because, they say, it shifts more authority of the program to states. Others say it would very likely lead some states to move many CHIP enrollees into either Medicaid or private insurance policies sold on the Obamacare exchanges — both areas where the federal government may pay an even higher share of the costs, Pope says.

“It’s not a simple win for anything, but you can see why some governors would like it,” he says.

At a House subcommittee hearing in June, some Republican lawmakers expressed concerns about extending the enhanced federal funding for CHIP.

“This increase in funding has challenged the program by both shifting the nature of shared responsibility of the state Children’s Health Insurance Program to the federal government and making states more dependent on federal dollars,” said Rep. Michael Burgess, R-Texas, who heads the Energy and Commerce subcommittee on health.

A committee staff memo prepared for the hearing suggested that taking away the extra funding (as some Republicans would like to do), but leaving the maintenance-of-effort requirement in place, would not result in fewer children having coverage.

Without renewal of the program, Arizona, Minnesota, North Carolina and the District of Columbia would run out of their federal CHIP funding by the end of this year. By March 2018, an additional 27 states would exhaust their funds.

Minnesota and D.C. officials say all children in those two regions who are covered by CHIP will transition to Medicaid if the federal funding is cut.

Alker says the enhanced funding included in CHIP’s 2009 reauthorization has helped several states, including Nevada and Utah. The states were able to expand coverage to legal immigrant children immediately; before that extra money came in, these kids faced a five-year wait for insurance.

Given the complexity of making major changes and the tight congressional timeline, some experts say Congress may opt to pass a clean CHIP bill — without major changes to the program.

“Congress is in [session] this month so few days that I can easily see CHIP simply being reauthorized without strings attached,” says Joe Antos, a health economist with the conservative American Enterprise Institute. Lawmakers’ attention is more likely to focus on the debt-limit deadline, the budget resolution and tax reform, Antos says.

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Phil Galewitz is a senior correspondent for KHN.

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After Republicans in the Senate spectacularly failed to deliver on their promise to repeal and replace the Affordable Care Act, also known as Obamacare, a smaller group of lawmakers is trying a new approach: bring in the Democrats and aim low.

It starts Wednesday when the Senate Health, Education, Labor and Pensions Committee holds the first of four hearings over two weeks with the goal of passing a modest bill to help stabilize the Obamacare health insurance markets for 2018.

Committee Chairman Lamar Alexander, R-Tenn., says he’s looking to do something “small, bipartisan and balanced.”

What’s remarkable is that he made that statement in a joint press release last month with the committee’s ranking Democrat, Sen. Patty Murray, D-Wash.

Up until recently, all major Republican efforts to alter Obamacare were launched with no Democratic support, and no attempts to get any.

Alexander and Murray say they want to work first to stabilize the markets for next year and then perhaps move on to broad reforms that will attract more insurance companies to compete in the individual markets, potentially making prices lower for consumers.

They’ve got a short window. Insurance companies have until Sept. 27 to sign contracts committing them to offering health plans on the Affordable Care Act exchanges next year, and setting their prices.

Alexander says his priorities include getting Congress to commit to funding so-called cost-sharing subsidies – payments that reimburse insurance companies for giving their lowest-income customers discounts on deductibles and co-payments.

President Trump has threatened to end the payments, and has refused to even say whether the government will make them for the final four months of this year.

“State insurance commissioners have warned that abrupt cancellation of cost-sharing subsidies would cause premiums, copays and deductibles to increase and more insurance companies to leave the markets in 2018,” Alexander said in a statement last month. “Congress now should pass balanced, bipartisan, limited legislation in September that will fund cost-sharing payments for 2018.”

He also wants the federal government to make it easier for states to get waivers so they can implement health policies that differ from Obamacare.

Wednesday’s hearing will feature insurance commissioners from four states, including Julie Mix McPeak from Alexander’s home state of Tennessee. She’s called for assurances that the payments will continue.

“When there’s any uncertainty surrounding the continuation of those payments, the insurers are doing two things. They are raising premium rates for 2018 and they’re making decisions about whether or not to participate in the individual exchange markets across the nation,” McPeak told NPR’s Ari Shapiro in August.

On Thursday, governors from four states will testify. They include John Hickenlooper of Colorado, who together with Gov. John Kasich of Ohio recently proposed their own bipartisan plan to overhaul the insurance markets.

Their plan includes creating a two-year reinsurance fund to protect insurers from people who have severe illnesses and make big claims. It would also exempt insurance companies from certain taxes if they enter a market in which there’s little to no competition.

The governors’ plan also advocates maintaining the so-called individual mandate, which requires everyone to own health coverage or pay a fine. That mandate is one of the most hated elements of Obamacare among republicans and President Trump has suggested that his administration will make little effort to enforce it.

Hickenlooper and Kasich laid out their plan last week in a letter to congressional leaders that was signed by the Republican and Democratic governors of eight states, including Gov. Brian Sandoval of Nevada. By signing on to this proposal, Sandoval, a popular Republican, seems to be indicating he will not support the new health plan proposed by his fellow Nevadan, Sen. Dean Heller.

Throughout the late spring and summer, insurance companies filed plans with the federal government that included proposed premiums for the health insurance plans they intend to offer in 2018. Many said they were raising rates because they weren’t certain the Obama administration would enforce the individual mandate or pay the cost-sharing subsidies.

An analysis by the consulting firm Oliver Wyman suggest that by taking action to stabilize the market, lawmakers could boost enrollment by two million people while cutting prices.

HELP isn’t the only Senate committee pursuing the bipartisan approach. Finance Committee leaders Orrin Hatch, R-Utah, and Ron Wyden, D-Ore., are planning two hearings in the next two weeks on insurance markets and the Children’s Health Insurance Program.

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In health care, you could say radiologists have typically had a pretty sweet deal. They make, on average, around $400,000 a year — nearly double what a family doctor makes — and often have less grueling hours. But if you talk with radiologists in training at the University of California, San Francisco, it quickly becomes clear that the once-certaingolden path is no longer so secure.

“The biggest concern is that we could be replaced by machines,” says Phelps Kelley, a fourth-year radiology fellow. He’s sitting inside a dimly lit reading room, looking at digital images from the CT scan of a patient’s chest, trying to figure out why he’s short of breath.

Because MRI and CT scans are now routine procedures and all the data can be stored digitally, the number of images radiologists have to assess has risen dramatically. These days, a radiologist at UCSF will go through anywhere from 20 to 100 scans a day, and each scan can have thousands of images to review.

“Radiology has become commoditized over the years,” Kelley says. “People don’t want interaction with a radiologist, they just want a piece of paper that says what the CT shows.”

‘Computers are awfully good at seeing patterns’

That basic analysis is something he predicts computers will be able to do.

Dr. Bob Wachter, an internist at UCSF and author of The Digital Doctor, says radiology is particularly amenable to takeover by artificial intelligence like machine learning.

“Radiology, at its core, is now a human being, based on learning and his or her own experience, looking at a collection of digital dots and a digital pattern and saying ‘That pattern looks like cancer or looks like tuberculosis or looks like pneumonia,’ ” he says. “Computers are awfully good at seeing patterns.”

Just think about how Facebook software can identify your face in a group photo, or Google’s can recognize a stop sign. Big tech companies are betting the same machine learning process — training a computer by feeding it thousands of images — could make it possible for an algorithm to diagnose heart disease or strokes faster and cheaper than a human can.

UCSF radiologist Dr. Marc Kohli says there is plenty of angst among radiologists today.

“You can’t walk through any of our meetings without hearing people talk about machine learning,” Kohli says.

Both Kohli and his colleague Dr. John Mongan are researching ways to use artificial intelligence in radiology. As part of a UCSF collaboration with GE, Mongan is helping teach machines to distinguish between normal and abnormal chest X-rays so doctors can prioritize patients with life-threatening conditions. He says the people most fearful about AI understand the least about it. From his office just north of Silicon Valley, he compares the climate to that of the dot-com bubble.

“People were sure about the way things were going to go,” Mongan says. “Webvan had billions of dollars and was going to put all the groceries out of business. There’s still a Safeway half a mile from my house. But at the same time, it wasn’t all hype.”

‘You need them working together’

The reality is this: dozens of companies, including IBM, Google and GE, are racing to develop formulas that could one day make diagnoses from medical images. It’s not an easy task: to write the complex problem-solving formulas, developers need access to a tremendous amount of health data.

Health care companies like vRad, which has radiologists analyzing 7 million scans a year, provide data to partners that develop medical algorithms.

The data has been used to “create algorithms to detect the risk of acute strokes and hemorrhages” and help off-site radiologists prioritize their work, says Dr. Benjamin Strong, chief medical officer at vRad.

Zebra Medical Vision, an Israeli company, provides algorithms to hospitals across the U.S. that help radiologists predict disease. Chief Medical Officer Eldad Elnekave says computers can detect diseases from images better than humans because they can multitask — say, look for appendicitis while also checking for low bone density.

“The radiologist can’t make 30 diagnoses for every study. But the evidence is there, the information is in the pixels,” Elnekave says.

Still, UCSF’s Mongan isn’t worried about losing his job.

“When we’re talking about the machines doing things radiologists can’t do, we’re not talking about a machine where you can just drop an MRI in it and walk away and the answer gets spit out better than a radiologist,” he says. “A CT does things better than a radiologist. But that CT scanner by itself doesn’t do much good. You need them working together.”

In the short term, Mongan is excited algorithms could help him prioritize patients and make sure he doesn’t miss something. Long term, he says radiologists will spend less time looking at images and more time selecting algorithms and interpreting results.

Kohli says in addition to embracing artificial intelligence, radiologists need to make themselves more visible by coming out of those dimly lit reading rooms.

“We’re largely hidden from the patients,” Kohli says. “We’re nearly completely invisible, with the exception of my name shows up on a bill, which is a problem.”

Wachter believes increasing collaboration between radiologists and doctors is also critical.

“At UCSF, we’re having conversations about [radiologists] coming out of their room and working with us. The more they can become real consultants, I think that will help,” he says.

Kelley, the radiology fellow, says young radiologists who don’t shy away from AI will have a far more certain future. His analogy? Uber and the taxi business.

“If the taxi industry had invested in ride-hailing apps maybe they wouldn’t be going out of business and Uber wouldn’t be taking them over,” Kelley says. “So if we can actually own [AI], then we can maybe benefit from it and not be wiped out by it.”

At least for now, Kelley offers what a computer can’t — a diagnosis with a face-to-face explanation.

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St. Joseph Medical Center is downtown Houston’s only hospital, located just down the street from the convention center where thousands of evacuees have been staying since Harvey hit.

As of Friday, some doctors and nurses have been on the clock for almost a full week.

When you’re working in an ER during a major natural disaster, nothing is routine. Trent Tankersley, director of emergency services at St. Joseph Medical Center, describes one tense situation after another in the hospital this week.

“We had a lady who the only vehicle heavy enough and strong enough to get to her through the floodwaters was a dump truck. She was pregnant. She was in labor. She was brought to the hospital in the dump bed of a dump truck, soaking wet.

“As we were getting her over to the women’s building to get taken care of, we had a trauma come in. Shortly after that, we had a young man [who] came in that was having a stroke.”

Tankersley showed up to work Saturday, and hasn’t had what you’d consider “a break” since.

“Finally got to go home last night for a couple hours and do some laundry and then came right back. So it’s been an interesting five or six days.”

Some staff haven’t been home since before Harvey struck

Kristen Benjamin, an associate chief nursing officer, has been right beside Tankersley.

“I think we’re all working on adrenaline right now. We’re working shift by shift. Some people are doing 15-, 16-hour shifts. We let them go off and sleep. They come back in.”

They’ve seen more than 600 patients in the first five days. At times, they saw more patients in a few hours than they usually would in a whole day.

Many staffers have been stuck at the hospital, with no clear path to their homes. As floodwaters recede, their coworkers can finally come back.

“We’re going to start transitioning staff out to get home so that they can check on their homes,” Benjamin says. “Because some of them don’t even know what’s happening at their house right now because they haven’t been home since Friday. So I don’t even really have an idea if their house has been flooded or not.”

His first day working in the ER

Among those staffing the ER are doctors from other departments pitching in, and even medical students, like Diana Johnson. She and her classmates are using a Google spreadsheet to organize shifts to help.

She’s in her third year at Houston’s McGovern Medical school. She’s assisting Dr. Winston Watkins, an internist on his first day in the ER.

“One of the first patients that came in happened to be one of my own patients from my practice, and he came in with his foot hurting,” he says.”So Diana evaluated him and it turns out he has gangrene of his right fourth toe. And so we’re going to admit him to the hospital.”

“Some of them don’t even know what’s happening at their house right now because they haven’t been home since Friday.”

His house is underwater

Nurse Aaron Padron says he’s never seen such a wide range of emotions in the ER.

“A lot of laughter crying yelling, tears,” he says. “People that you work with you think that wouldn’t crack just put their head in their hands and take a second to cry to themselves, or not to themselves, and wipe away the tears and get back to work.”

He’s been working here for most of the last week, except Saturday night.

“I went home on Saturday to sort of rescue my family before the floods got too high for me to get in or out,” he says. “And then I came back Sunday and I’ve been working and sleeping here ever since.”

Neighbors say his house is underwater. He says several others working in the ER saw their homes flooded. In a way, he says, it’s all been a transformational experience.

“I think times of crisis, in times of emergency, in times of stress really have a way to bring people together and create a lot of camaraderie and really can push people to excel at what they do,” he says.

Once reinforcements come in, he’ll be able to rotate off his shift and find out just how much his family lost.

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Earlier this week, as torrents of rain fell on Houston, Craig Boyan, CEO of the H-E-B supermarket chain, went on a video-taped tour of his company’s emergency operations center in San Antonio, Texas. The company later made the video available online.

It was a revealing look inside a logistical nightmare. Boyan walked through two crowded, windowless rooms, stopping to speak with the people responsible for reopening stores, locating employees (or, as the company calls them, “partners”) to staff those stores, organizing deliveries of water and ice, and figuring out how to line up fresh supplies of milk, eggs and bread despite the city’s waterlogged streets.

One example: H-E-B makes most of its own bread, and its two bread-making plants are located in Corpus Christi and Houston. When the storm hit, “we had to take Corpus down, run the whole company out of Houston,” Boyan explained in the video. When the storm moved on toward Houston, “we had to switch back to Corpus, now we’re on generator power” at that plant. But the company’s supply of fresh bread was never interrupted.

There was a lot more than H-E-B’s own business at stake. Every day without deliveries of food and water could mean hunger for many thousands of people. “One of the things we’re really proud of is being the last to close and the first to open,” Boyan said.

Indeed, H-E-B and other big supermarket chains managed to get stores open and trucks rolling from warehouses at an impressive pace this week.

On Tuesday, at the height of the flooding, Walmart had closed 134 Houston-area storms. By Thursday, only 21 stores remained closed. H-E-B also had reopened almost 90 percent of its stores by then. Of the 20 stores owned by Albertson’s, 16 are now open.

According to Ragan Dickens, a Walmart spokesman, “very few” of the company’s stores actually flooded. The company had to throw out some perishable food, but it was able to reopen any stores that were accessible to trucks and had electrical power.

Dickens says that customers at some locations have been forced to line up outside to prevent overcrowding inside. And some stores remain closed because workers and trucks can’t get to them through flooded roads.

The ability of Houston’s big grocery chains to rebuild their supply chains “is amazing, but not surprising,” says Roni Neff, a professor of Environmental Health and Engineering at Johns Hopkins University. Neff recently co-authored a report on ways that the city of Baltimore could ensure continued food supplies in the face of future disasters, including possible flooding.

“We did a whole set of interviews, and we found that the bigger chains and the bigger businesses had very extensive planning in place” for natural disasters, Neff says.

City governments, on the other hand, don’t always think enough about food supply in their emergency planning, she says. In Baltimore, for instance, “there was an emergency operations center, but nobody [overseeing] food was there.”

Baltimore has now changed that. The city now has a “food resilience coordinator” who is part of emergency planning. “This is something that very few places have done in the past,” Neff says. “I really believe it’s something that everybody should be looking at.”

According to Neff, governments do need to be involved, in addition to supermarkets. “In Houston, as everywhere, the impacts are not equally felt,” she says. “People with lower incomes, people who are elderly, with disabilities, with medically necessary diets, may be particularly hit by this kind of situation, and really have quite severe food security threats to them.” And city governments need to be prepared to get food to these, more vulnerable groups.

In Houston, many supermarket chains, including Walmart, H-E-B, and Albertson’s, have also helped in relief measures. They have delivered truckloads of water and food to large shelters and to food banks, which in turn send food to distribution points in other parts of Houston and nearby areas.

Trucks were only able to reach the central Houston Food Bank starting Wednesday evening. “Now, the wheels are spinning, literally and figuratively,” says Paula Murphy, who handles public communication for the organization.

Seventeen truckloads of non-perishable food and water from Walmart were scheduled to arrive on Thursday, along with three airplane loads of food flown in from Dallas. “As soon as it arrives, it goes out again,” she says. “Our fleet of trucks is out there. The area we can reach is expanding.”

The biggest need, she says, is probably in rural areas outside Dallas, far from any supermarkets, where roads still may be impassable.

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In southeastern Texas, about two dozen hospitals remained closed as of midafternoon Wednesday, and several Houston hospitals remain under threat of flooding from nearby reservoirs.

But things are looking up. Some hospitals that had been evacuated have reopened, and others are restoring services they had temporarily suspended. Many never closed at all.

A catastrophic medical operations center, housed within Houston’s emergency center, has been coordinating with hospitals throughout the storm and continues to field calls about patients needing evacuation or immediate medical attention.

All Things Considered host Kelly McEvers spoke with Darrell Pile, CEO of the Southeast Texas Regional Advisory Council, which runs the catastrophic medical operations center.

This interview has been edited for length and clarity.

Interview Highlights

While the storm has largely left Houston, the flooding continues. What is the situation with the hospitals you’re working with?

The flooding is devastating, and we have at least two reservoirs where water is having to be released and is, in fact, flooding neighborhoods as we speak and has placed three hospitals in harm’s way.

The three hospitals are monitoring the water coming from the two reservoirs very closely, and they could, depending on the flow of the water, find that they could become inaccessible to EMS agencies. We are tracking that very closely.

The situation with residents in their homes — some are on the second floor of their homes — the evacuation process [for those neighborhoods] continues, and, as a result, it’s unclear what the demands on the health care system may be. However, most hospitals are up and fully functional, and we believe we can handle any new demands that happen today or tomorrow.

Has the catastrophic medical operations center ever handled anything like this?

No. The phone lines at one point became inundated. The amount of resources needed began to exceed what we had available. The calls included patients needing dialysis who might be at home. It included hospitals saying we need to evacuate. One call was asking for 50 wheelchairs to be sent to a shelter. We didn’t have 50 wheelchairs left. Fortunately, our governor declared a disaster and the president declared a disaster and resources have been brought in from all over the state and all over the nation to help us.

How did you get those 50 wheelchairs?

I’m not clear on how they ended up getting the 50 wheelchairs, but I can tell you, it can be accomplished just through one or two tweets to Houstonians. Those with wheelchairs perhaps in their attic or stored [elsewhere] could bring an abundance of wheelchairs, perhaps more than you even need. So there are methods to solve every problem. It’s just having enough people to make the calls or to be innovative and creative to solve the problems. This community has come to the call.

A number of hospitals did evacuate, either prior to the storm or during. How difficult is it to evacuate a hospital?

It’s not as simple as pulling up a bus or a convoy of ambulances and moving patients from one hospital to another hospital. My organization makes sure that the receiving hospital meets the need of every single patient they agree to receive. As a result, the evacuation of a hospital might mean we must identify 10 different hospitals to meet the unique needs of each patient.

Every day, three times per day, we have hospitals electronically advise us of beds that they have available and the type. So a pediatric patient goes to a pediatric bed.

And we’ve also spent time making sure the receiving hospital is not in harm’s way so that the patient would not have to be evacuated twice. We have worked with the [Texas] Department of State Health Services to also identify hospitals with beds available in cities such as Dallas or San Antonio or Austin or even further away so that a patient doesn’t move twice.

We’ve heard news of at least one hospital being short of food. Has that been resolved?

Yes. I was intimately involved in the Ben Taub [Hospital] decision to evacuate, and I was aware of their call for food. It was not a problem that was devastating or affecting patient care to any significant extent, and it did not last throughout the disaster period.

We do have to deal with situations where we have to dig down and find out the truth and make sure our response is responding to facts and not to stories that might have had some facts at one point, but as days went by, it became a little distorted.

[Editor’s note: Ben Taub Hospital confirmed to NPR that they have reopened, that supply lines are steadily improving and that they have received a food delivery and are expecting another one today.]

A number of Houston hospitals added flood protections as a result of other devastating storms, including Allison in 2001. Have those worked?

Absolutely. We had a situation where in prior storms, water came into a tunnel system that connects the Texas Medical Center hospitals. [The tunnels] make it easier to go from one hospital to another hospital. However, waters came in and flooded every hospital through that tunnel system.

The Texas Medical Center invested in submarine-type doorways, and when there is a risk of flooding, they now close those doorways. So each hospital is compartmentalized. As a result, this storm — even though flooding devastated our community, it did not devastate Texas Medical Center. So, congratulations to the Texas Medical Center.

Do the hospitals have the staff they need right now?

I can imagine some of the hospitals have fewer employees available to staff the hospital. Some members of their workforce have lost everything — their homes destroyed, their automobiles destroyed.

Tomorrow, we will be holding a meeting to discuss what do our hospitals need. And from there we will be identifying where we need to place nurses. We have an abundance of nurses from throughout Texas who have offered to help. We also have an abundance of physicians who have offered to help. Now it’s a matter of making sure we place them in the proper facilities.

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As floodwaters continue to rise in parts of Houston, health workers are trying to keep people safe and well, though that challenge is escalating.

“The first and foremost thing that everybody’s concerned about is just getting folks out of harm’s way with the flooded waters,” says Dr. Umair Shah, Executive Director of Harris County Public Health, whose own home came under mandatory evacuation Tuesday morning.

Before the storm hit, Harris County Public Health sent out a number of messages warning residents of to avoid hazards presented by flood waters: downed power lines, sewage contamination, rusted nails and the possibility of critters in the water — everything from snakes to spiders to alligators.

Now that people are showing up in shelters, efforts are turning to helping people with both health issues arising from the flood — including respiratory and gastrointestinal problems — and with getting care for preexisting conditions, some of which can be life-threatening if not treated promptly.

“That doesn’t even obviously take into account the numerous injuries and the mental health issues that all come into play. So it’s a very complicated response system,” Shah tells All Things Considered host Ari Shapiro.

Shah remembers that after Hurricane Katrina in 2005, health workers set up clinics in shelters and asked people with anxiety or schizophrenia to come forward. Many were not willing to do so. “So we actually had to fan into the shelter to identify ourselves mental health issues,” Shah recalls. “That’s a big component and something we’re also mindful of now.”

At the George R. Brown Convention Center in downtown Houston, licensed clinical social worker Brittany Burch showed up to help some of the thousands of people who have taken shelter there. As she tells NPR, she’s already seeing and hearing a lot of distress.

“A lot of people really overwhelmed, stories of having to jump in a boat or get a helicopter out, wade through waist-high water, losing everything,” she says. “So just a lot of people in shock, trying to adjust to what’s happened and what happens from here.”

Burch has heard from people who, before the storm, already suffered from chronic depression, post-traumatic stress disorder, bipolar disorder and other illnesses. “Some people haven’t been on their medications for a few days,” she says. “So there’s a lot of stress just being here, and then the extra mental health needs that arise in the midst of this [are] also very challenging.”

“There is such an unmet medical need,” says Kristin Malaer, another social worker who also showed up to volunteer. “Just going and connecting with people, you find out so many of them are diabetic or so many of them have chronic medical illness, that serving them all is pretty overwhelming.”

Among the more pressing medical issues is getting treatment to the sizeable population of people on dialysis.

DaVita, a leading provider of dialysis services nationwide, says the company normally serves approximately 6,700 patients in Houston. About a third of their 100 or so centers in the city remain open for all patients who need dialysis, according to Chakilla Robinson White, who oversees operations at DaVita’s dialysis centers in Texas and neighboring states.

“We are trying to call proactively and ensure that those patients we know need treatment are seeking treatment, either with us or within a hospital system,” White says. “We’re like, ‘Hey, we would like to see you in a center. What do we need to do to be able to get you here?’ “

For patients they reach who are stuck in their homes, surrounded by flood water, they’re trying to arrange transportation. “We’re alerting the authorities that this is a medical emergency so that they can get prioritized,” she says.

Gail Torres, senior clinical communications director for the National Kidney Foundation, says forgoing dialysis treatment for even a day can be extremely dangerous, particularly to the heart.

“Certain toxins can build up, but most importantly, potassium and fluid can affect the heart,” she says. “If you have a buildup of potassium, depending on what their baseline is, it can send them into cardiac arrest.” She says that delays in treatment can result in cumulative damage, as they saw after Hurricane Katrina in 2005 and Superstorm Sandy in 2012.

In Houston, DaVita is working to bring in enough staff to keep dialysis centers open, calling in workers from other cities and states and also finding ways to get their Houston-based colleagues to work.

“We’re working on bringing in boats to actually get our teammates in some of the neighborhoods where they’re unable to escape through the flood,” White says. “It’s amazing how many teammates have had hardships themselves, losing part of their homes and still showing up to treat our patients.”

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More than one-quarter of serious cases of nursing home abuse are not reported to the police, according to an alert released Monday morning by the Office of Inspector General in the Department of Health and Human Services.

The cases went unreported despite the fact that state and federal law require that serious cases of abuse in nursing homes be turned over to the police.

Government investigators are conducting an ongoing review into nursing home abuse and neglect but say they are releasing the alert now because they want immediate fixes.

These are cases of abuse severe enough to send someone to the emergency room. One example cited in the alert is a woman who was left deeply bruised after being sexually assaulted at her nursing home. Federal law says that incident should have been reported to the police within two hours. But the nursing home didn’t do that, says Curtis Roy, an assistant regional inspector general in the Department of Health and Human Services.

“They cleaned off the victim,” he says. “In doing so, they destroyed all of the evidence that law enforcement could have used as part of an investigation into this crime.”

The nursing home told the victim’s family about the assault the next day. It was the family that informed the police. But Roy says that even then, the nursing home tried to cover up the crime.

“They went so far as to contact the local police department to tell them that they did not need to come out to facility to conduct an investigation,” says Roy.

Looking at records from 2015 and 2016, Curtis Roy and his team of investigators found 134 cases of abuse of nursing home residents severe enough to require emergency treatment. The vast majority of the cases involved sexual assault.

“There’s never an excuse to allow somebody to suffer this kind of torment, really, ever,” says Roy.

The incidents of abuse were spread across 33 states. Illinois had the most at 17. Seventy-two percent of all the cases appear to have been reported to local law enforcement within two hours. But twenty-eight percent were not. Investigators from the Office of the Inspector General decided to report all 134 cases to the police. “We’re so concerned,” says Roy, “we’d rather over-report something than not have it reported at all.”

The alert from the Inspector General’s office says that the Centers for Medicare and Medicaid Services (CMS), which regulate nursing homes, need to do more to track these cases of abuse. The alert suggests that the agency should do what Curtis Roy’s investigators did: cross-reference Medicare claims from nursing home residents with their claims from the emergency room. Investigators were able to see if an individual on Medicare filed claims for both nursing home care and emergency room services. Investigators could then see if the emergency room diagnosis indicated the patient was a victim of a crime, such as physical or sexual assault.

The alert notes that federal law on this issue was strengthened in 2011. It requires someone who suspects abuse of a nursing home resident causing serious bodily injury, to report their suspicion to local law enforcement in two hours or less. If their suspicion of abuse does not involve serious bodily injury of the nursing home resident, they have 24 hours to report it. Failure to do so can result in fines of up to $300,000.

But CMS never got explicit authority from the Secretary of Health and Human Services to enforce the penalties. According to the Inspector General’s alert, CMS only began seeking that authority this year. CMS did not make anyone available for an interview.

Clearly, the 134 cases of severe abuse uncovered by the Inspector General’s office represent a tiny fraction of the nation’s 1.4 million nursing home residents. But Curtis Roy says the cases they found are likely just a small fraction of the ones that exist, since they were only able to identify victims of abuse who were taken to an emergency room. “It’s the worst of the worst,” he says. “I don’t believe that anyone thinks this is acceptable.

“We’ve got to do a better job,” says Roy, of “getting [abuse] out of our health care system.”

One thing investigators don’t yet know is whether the nursing homes where abuses took place were ever fined or punished in any way. That will be part of the Inspector General’s full report which is expected in about a year.

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