TIME Health Care

Many Teens Are Still Not Getting The HPV Vaccine

Even though the HPV vaccine prevents cancer, the number of teens who get vaccinated is still lower than desired

New federal data shows that despite public health efforts, the number of teen boys and girls receiving the human papillomavirus (HPV) vaccine only increased slightly in 2014.

The new numbers from the U.S. Centers for Disease Control and Prevention (CDC) released on Thursday show that four out of 10 adolescent girls and six out of 10 adolescent boys have not started the HPV vaccination series. Without vaccination, young people are at a greater risk of developing HPV-related cancers down the line.

Overall, 60% of girls in the age group and 42% of boys have received one or more doses of the vaccine which the CDC reports is 3% higher for girls and 8% higher for boys compared to data from 2013.

Currently it is recommended by the CDC that girls and boys ages 11 to 12 get the HPV vaccine. While the new numbers are an improvement from prior years, medical experts would like to see greater HPV vaccine use, especially since the vaccine prevents cancer.

HPV is not an uncommon infection. Other data from the CDC shows sexually active men and women will get at least one type of the virus at some point during their lives. Each year around 27,000 people in the U.S. are diagnosed with HPV-caused cancer.

We are missing crucial opportunities to protect the next generation from cancers caused by HPV,” said Dr. Anne Schuchat, assistant surgeon general and director of CDC’s National Center for Immunization and Respiratory Diseases in a statement.

MONEY Opinion

Medicare Is Part of the Solution to Rising Health Care Costs

Democratic House Leader Nancy Pelosi Marks 50th Anniversary Of Medicare And Medicaid With Senate And House Lawmakers
Astrid Riecken—Getty Images Seniors listen to Democratic House Leader Nancy Pelosi mark the 50th Anniversary of Medicare and Medicaid on Capitol Hill on July 29, 2015 in Washington, DC. Pelosi was joined by Senate and House lawmakers who oppose any cuts to the important program for seniors.

The health insurance program's massive size gives it the power to set prices that providers will accept.

Medicare turns 50 on Thursday, riding high in the polls but under attack from presidential candidates proposing benefit cuts or even phasing out the U.S. healthcare program for older people.

When President Lyndon Johnson signed the law, half of Americans age 65 or older had no health insurance. Today, just 2% go uncovered.

And the public really, really likes Medicare, which last year covered 54 million Americans. A poll released earlier this month by the Kaiser Family Foundation found strong support across political party lines for Medicare and Medicaid, which insures low-income Americans and became law alongside Medicare.

But Medicare still sticks in the craw of conservatives.

“We need to figure out a way to phase out this program for (people who are not already receiving benefits) and move to a new system that allows them to have something, because they’re not going to have anything,” Republican presidential contender Jeb Bush told an audience of conservatives in New Hampshire last week.

Bush later tried to walk back his comment, but he is not alone in his desire to euthanize Medicare just as it hits midlife.

Fellow Republican presidential candidate Chris Christie has proposed raising the eligibility age for Medicare and Social Security to 69.

Beyond all the noise lies an important question: how to best pay for health care for our aging population.

In 2050, the 65-and-older population will reach 83.7 million, almost double what it was in 2012, according to the U.S. Census Bureau. That, along with rising healthcare costs, means Medicare will account for a rising share of the federal budget in the years ahead.

The line of attack against Medicare is that its finances are not sustainable, but what we really have is a healthcare cost problem, not a Medicare problem.

The program is funded through two trust funds.

The Hospital Insurance fund, which finances Medicare’s Part A hospital benefits, receives money mainly from the 1.45% payroll tax that employees pay and employers match. This fund is projected to run dry in 2030, leaving Medicare able to meet only 85% of that part of the program’s costs.

Meanwhile, the Supplementary Medical Insurance trust fund finances outpatient services and the Part D prescription drug program. It gets 75% of its funding from general tax revenues and 25% from yearly premiums that beneficiaries pay. It will stay solvent because contributions are reset annually to match anticipated spending, but that is expected to put more pressure on government and household budgets in the years ahead, especially if healthcare inflation takes off.

Medicare actually does a better job of restraining spending growth than private health insurance because its massive size gives it the power to set prices that providers will accept. And the Affordable Care Act mandated constraints in provider payments that have been paying off.

Medicare spending has been slowing in recent years. Reflecting that, the annual Part B (outpatient services) premium has been flat at $104.90 for the past three years.

Medicare’s trustees projected last week that the program’s total spending as a percent of the gross domestic product would rise from 3.5% to 5.4% in 2035. That is “not nothing, but neither is it insurmountable,” says Jared Bernstein, an economist and senior fellow at the Center on Budget and Policy Priorities.

The gap can be closed through efficiencies. We could change the law to allow the government to negotiate drug prices with pharmaceutical companies, for example. Or a small increase in the Medicare payroll tax from 1.45% to 1.8% would do the trick.

The conservative plan, however, is to reduce the value of Medicare’s benefits. That can be done by raising the eligibility age, effectively a lifetime benefit cut, or by replacing the program’s set of defined benefits with something called “premium support.”

With that, people would receive a voucher that they could use to purchase private insurance plans. Bush was showcasing that idea in his New Hampshire remarks.

A phase-out or redesign of Medicare will mean higher out-of-pocket costs in a program where the median income of enrollees is just $23,500 per year.

“These folks would unquestionably be worse off in the absence of Medicare,” Bernstein said.

Instead, we should continue working on reforming the delivery of care and negotiate savings with pharmaceutical companies.

And we should wish our most important health insurance program a happy birthday. Medicare, you are part of the solution, not the problem.

Read next: Medicare Turns 50 But Big Challenges Await

MONEY Medicare

Medicare Turns 50 But Big Challenges Await

President Lyndon Johnson signing Medicare Bill in Independence, Missouri while Harry Truman looks on, July 30, 1965.
Universal History Archive—Getty Images President Lyndon Johnson signing Medicare Bill in Independence, Missouri while Harry Truman looks on, July 30, 1965.

Medicare provides coverage to one in six Americans, and federal officials look to find ways to trim the increasing cost and improve how the program operates.

Medicare, the federal health insurance program for the elderly and disabled, has come a long way since its creation in 1965 when nearly half of all seniors were uninsured. Now, the program covers 55 million people, providing insurance to one in six Americans. With that in mind, Medicare faces a host of challenges in the decades to come. Here’s a look at some of them.

Financing – While Medicare spending growth has slowed in recent years – a trend that may continue into the future – 10,000 people a day are becoming eligible for Medicare as the trend-setting baby boomers age. Yet the number of workers paying taxes to help fund the program is decreasing. That means Medicare will consume a greater share of the federal budget and beneficiaries’ share of the tab will likely climb. An abundance of proposals to curb federal expenditures on Medicare exist. They include increasing the eligibility age, restructuring benefits and cost-sharing, raising the current payroll tax rate and asking wealthier beneficiaries to pay more for coverage. Many Republicans have backed a “premium support” model — where the government would give beneficiaries a set amount of money to purchase coverage from a number of competing plans — as a way to limit Medicare spending. Democrats say premium support would undermine traditional Medicare and shift more of the program’s financial risk to beneficiaries. They favor other reforms in the program. By at least two-to-one margins, majorities of Democrats, Republicans and independents favor keeping Medicare as it is rather than changing to a premium support program, according to a recent poll from the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

Affordability — Most Medicare beneficiaries don’t have a lot of money and spend a large chunk of their finances on health care. Unlike many private health insurance plans, there is no cap on out-of-pocket expenditures in traditional Medicare, and the program does not cover services that many beneficiaries need, such as dental care and eyeglasses. (Private insurers that participate in Medicare Advantage may cover these and other items that traditional Medicare does not.) In 2013, half of all people on Medicare had incomes below $23,500 per person, and premiums for Medicare and supplemental insurance accounted for 42 percent of average total out-of-pocket spending among beneficiaries in traditional Medicare in 2010, according to an analysis from the Kaiser Family Foundation. Medicare does have some programs to help beneficiaries pay their Medicare expenses but the income limits can be as low as $1,001 per month with savings and other assets at or below $7,280 (limits are higher for couples).

Managing Chronic Disease — Illnesses such as heart disease or diabetes can ring up huge medical costs, so keeping beneficiaries with these conditions as healthy as possible helps not only the patients but also Medicare’s bottom line. An analysis from the Urban Institute finds that half of all Medicare beneficiaries will have diabetes in 2030 and a third will be afflicted with heart disease. Nearly half of the people on Medicare have four or more chronic conditions and 10 percent of the Medicare population accounts for 58 percent of spending. Reducing the rate of chronic disease by just 5 percent would save Medicare and Medicaid $5.5 billion a year by 2030 and reducing it by 25 percent would save $26.2 billion per year, the Urban Institute found. As beneficiaries age, many will want to remain in their homes and communities, requiring Medicare to identify ways to serve these beneficiaries as they face physical and cognitive impairments and meet their needs for more personal care, according to the Commonwealth Fund.

Delivery-System Reform — Medicare hopes to better manage beneficiaries’ needs by revolutionizing the way in which it pays for medical care. Federal officials have taken several steps to better coordinate and improve medical care, including implementing the health law’s requirement to reduce preventable hospital readmissions and form accountable care organizations, or ACOs, where doctors and others band together to care for patients with the promise of getting a piece of any savings. Another federal effort uses bundled payments, where Medicare gives providers a fixed sum for each patient, which is supposed to cover not only their initial treatment but also all the follow-up care. Last year, 20 percent of traditional Medicare spending — $72 billion — went to doctors, hospitals and other providers that coordinated patient care to make it better and cheaper. Department of Health and Human Services Secretary Sylvia M. Burwell has said that by the end of 2018 Medicare aims to have half of all traditional program payments linked to quality.

The Growth of Medicare Advantage — Enrollment in these private plans that offer alternative coverage is growing sharply. But the health law seeks to cut the rate at which the government reimburses insurers to make it closer to what it spends on beneficiaries in traditional Medicare. Nearly a third of beneficiaries are enrolled in Medicare Advantage plans. Many of the plans provide benefits beyond what traditional Medicare covers, such as eyeglasses and dental care, as well as lower out-of-pocket costs. But as federal payment rates decline the plans may become less generous. Another factor to watch is concentration in the Medicare Advantage market with just a handful of insurers now accounting for more than half of enrollment.

Kaiser Health News (KHN) is a nonprofit national health policy news service.

Read next: Medicare Is Part of the Solution to Rising Health Care Costs

MONEY

Think Health Care is Pricey? Get Ready to Spend Even More

pile of prescription medicine pills and tablets
Jan Mika—Shutterstock

Soon one out of every five dollars Americans spend will to go healthcare.

For the past six years Americans have gotten a respite from fast-rising health care costs. No more.

With millions of baby boomers entering retirement and pricey new drugs hitting the market, U.S. health care spending, which had increased at relatively moderate 4% rate since the financial crisis, grew 5.5% last year, according to a new government study reported on Tuesday by The Wall Street Journal.

You can expect more too. The actuaries who calculated the figures, project that spending will average 5.8% between 2014 and 2024. By then, health care as a share of the nation’s overall economy will have grown to 19.4% from 17.4% in 2013. In other words, our nation’s medical bills will account for one out of every five dollars we spend.

The changes aren’t totally unexpected. A big part of the extra costs are tied to the fact that baby boomers — many now in their 60s — are requiring more care. Important but expensive new drugs, like one that helps treat Hepatitis C, are also a factor, according the Journal.

Still, the rising costs aren’t good news, especially considering a key promise of the Affordable Care Act, which brought access to health insurance to millions of Americans, was to get the growth in health care spending under control, a goal known as “bending the curve.”

For people who get their health insurance coverage at work, rising costs are likely to mean a continued push by employers toward high-deductible plans, which can have steep out-of-pocket costs. Read here for more on tools for keeping medical bills under control.

MONEY Health Care

The Crazy High Price of Adult Braces

465879363
Jason Todd—Getty Images

The number of adults wearing braces today is 37% higher than in 1989, but insurance rarely covers the bill.

Danielle Faust, 33, is six weeks into wearing braces to fix her crooked teeth and is pretty happy about the process, but not the price. While the $5,000 for Invisalign clear aligners in South Florida where she is a freelance writer is $1,000 less than a friend is paying in New York, she is kicking herself because she missed out on a Groupon that would have saved her even more.

Parents often blanch at the price tag of braces for their children but count it as a known cost of raising offspring. When it comes to their own teeth, however, adults are a lot more cautious about the money involved. Using braces to fix dental problems such as crooked teeth or bite problems can cost between $3,000 and $7,000, depending on the treatment options and where you live.

The number of American adults over 18 sporting some form of a “brace face” is roughly 1.2 million, or 20% of the 5.9 million patients orthodontia patients nationwide, according to the American Association of Orthodontists. That is up from 875,000 adult patients in 1989.

“Adults are very careful. They are making the investment, and they want to make sure they are getting their money’s worth,” says Dr. Morris Poole, president of the AAO and a practicing orthodontist in Logan, Utah.

Shop Around

Most orthodontists charge a flat fee based on the duration and complexity of the case. Retainers and some follow-up care are usually included, says Poole.

As costs vary greatly, it pays to shop around. “Most will do a no-charge consultation,” says Dr. David Bonebreak, who participates in two orthodontic practices near Howard County, Maryland. If you like an expensive doctor more than others with cheaper plans, he suggests asking for price matching.

Katrina Morrison, a 38-year-old mom of three from Atlanta who works as a flight attendant for Delta Airlines, went to three different orthodontists for consultations and ended up going with the mid-priced one.

The more expensive option required a massive down payment of $1,000. The cheaper option was a discount chain that charged $99 a month, but did not offer a dedicated doctor with each visit.

“I really wanted that personalized service,” Morrison says.

Ask for Discounts

One way that Morrison saved money was by working all the breaks – the most significant being a family discount since she used the same orthodontist as her children. She also was able to pay upfront some of the $4,500 total cost and work out a payment plan over 20 months for the rest.

Insurance Varies

Morrison’s dental insurance covered 50% of her costs, but Faust’s insurance would not cover any of her Invisalign because it was considered cosmetic. If she had gone for traditional braces, it would have covered $2,000, but that would have been a lifetime benefit. Slightly less than half of the patients Poole sees have any sort of dental coverage at all, he says.

Rachel Teodoro, a 36-year-old mom and blogger from Seattle, Washington, was able to get some discounts by paying the $6,500 charge upfront and in cash, which she was able to do because her family had socked away money in their Health Savings Account.

“It makes sense to fund it, because it’s not taxed – and it’s a smart financial move,” Teodoro says.

Wear Your Retainer

The biggest cost-saver for braces: Wear your retainer. The best way to avoid future costs is to stick with the maintenance program.

“I would never let my teeth go again,” Morrison says. She just got her braces off in early July and is now facing a long run of wearing top and bottom retainers – replacements cost $250 a pop. “I’m always on the go, I’ve told myself I’ve got to hold onto these things,” she says.

MONEY Health Care

5 Challenges Facing Medicaid at 50

babies in hospital nursery
Corbis

The federal-state health care program covers nearly half of all births, one-third of children across the country and two-thirds of people in nursing homes.

A “sleeper” provision when Congress created Medicare in 1965 to cover health care for seniors, Medicaid now provides coverage to nearly 1 in 4 Americans, at an annual cost of more than $500 billion. Today, it is the workhorse of the U.S. health system, covering nearly half of all births, one-third of children and two-thirds of people in nursing homes.

Enrollment has soared to more than 70 million people since 2014 when the Affordable Care Act began providing billions to states that chose to expand eligibility to low-income adults under age 65. Previously, the program mainly covered children, pregnant women and the disabled.

Unlike Medicare, which is mostly funded by the federal government (with beneficiaries paying some costs), Medicaid is a state-federal hybrid. States share in the cost, and within broad federal parameters, have flexibility to set benefits and eligibility rules.

Though it provides a vital safety net, Medicaid faces five big challenges to provide good care and control costs into the future:

  1. Controlling costs — Medicaid is one of the largest items in state budgets, although its beneficiaries lack political clout. Expenses typically soar during economic downturns as enrollment increases when people lose jobs and their health benefits. That puts states in a quandary because they struggle to keep up with higher costs as their tax revenues decline. Medicaid enrollment and costs grew markedly during the last recession and enrollment shot up further since 2014 as a result of the 2010 health law (although the federal government pays the full cost of newly eligible enrollees through 2016). States typically try to control costs by cutting payment rates to doctors and hospitals or reducing benefits—both of which can have negative effects on enrollees by making it harder to get care.
  1. Getting states to expand income eligibility under Obamacare — The Supreme Court’s 2012 ruling that states could decide whether to participate in the health law’s Medicaid expansion impaired Democrats’ efforts to expand eligibility nationwide. Twenty states, mostly in the South and interior West, have refused to participate, citing concerns about the program’s effectiveness and cost. As a result, more than 4 million people have been left without health insurance because they don’t make enough to qualify for federal subsidies to buy private coverage on the health law’s exchanges, even though they are ineligible for state Medicaid programs. Texas and Florida are the two largest states that declined to expand the program. President Barack Obama has accused state Republican leaders of playing politics, but few GOP leaders have budged.
  1. Better oversight of managed care – More than half of Medicaid enrollees now get care through private managed care companies, according to the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation). While the insurers tout their ability to offer budget predictability, questions remain about how well the companies improve quality and control costs. In managed care, health plans are paid a set monthly rate to cover each enrollee’s medical needs. The Obama administration has recently proposed rules that would limit how much these plans may spend on administrative costs and set standards to ensure enrollees have adequate access to hospitals and doctors – similar to those for private plans. A recent report by the inspector general of the Department of Health and Human Services found widespread inaccuracies in Medicaid managed care plans’ provider directories. Half of the doctors listed in the directories were unavailable because providers were not at that location, were not in the plan’s network or were no longer taking new patients.
  1. Ensuring access to doctors and dentists — Studies show people enrolled in Medicaid can get primary and preventive care as easily as those with private coverage, but have a harder time finding specialists and dentists who are willing to treat them. Nationally, the rate of doctors willing to see new Medicaid patients ranges widely, mostly because the payment rates vary significantly by state. A recent poll from the Kaiser Family Foundation found that low-income adults covered by Medicaid are somewhat more likely than those with other types of insurance to report access issues in the past 12 months. In a 2012 federal study, just 40 percent of New Jersey doctors accepted new Medicaid patients compared to 99 percent in Wyoming. While the federal government requires states to offer dental coverage for children, adult coverage is optional. Even when states offer adults coverage, patients often struggle to find dentists willing to see them because of low payment rates. In many places, community health centers have helped to meet the growing need for dental care, but patients can face long waits.
  1. Meeting growing demand for long term care–While Medicaid is often typecast as helping poor, inner-city families, it’s also the only safety net for millions of middle-class people who need long-term care at home or in nursing homes. More than 60 percent of nursing home residents rely on Medicaid for assistance. With the aging of the population accelerating in the next two decades, the demand for long-term care is expected to soar. While states have made progress shifting enrollees from more costly nursing homes to long-term care services at home and in community settings, more needs to be done.

Kaiser Health News (KHN) is a nonprofit national health policy news service.

TIME Cancer

Top Cancer Doctors Call for Lower Drug Costs

Stethoscope checking hand holding dollar coins
Getty Images

“It’s time for patients and their physicians to call for change"

A group of cancer doctors are joining grassroots organizers and politicians in pleading with pharmaceutical companies to reduce the cost of cancer treatments.

In an editorial that ran Thursday in the Mayo Clinic Proceedings journal, 118 cancer experts produced a series of recommendations they say would lead to a reduction in treatment expenses. The doctors say that one in three individuals will be burdened with cancer in their lifetime, but out-of-pocket drug costs could easily exceed the average household income of an insured patient.

Four doses of one particular cancer drug, according to a report published in Mayo Clinic Proceedings in 2012, costs a staggering $120,000.

“It’s time for patients and their physicians to call for change,” said Dr. Ayalew Tefferi, a Mayo Clinic hematologist in a press release.

Among the recommendations are allowing Medicare to negotiate prices, permitting cancer drug imports for individual patients, and passing laws to keep drug companies from delaying access to generic drugs.

The physician’s recommendations come on the heels of a change.org petition led by patients that calls for a reduction in drug costs, particularly for cancer patients.

MONEY Medicare

What You Can Expect from Medicare on Its 50th Anniversary

Doctor prescribing medication to senior man
Getty Images

As it turns 50, Medicare faces big financial shortfalls and sweeping changes.

America’s landmark government health care programs, Medicare and Medicaid, celebrate their 50th anniversaries on July 30th. (The other key safety net, Social Security, turns 80 in August.) Decades into operation, the future of these plans is still hotly debated in Washington, as policymakers wrangle over needed changes in their finances. Two major reforms are already underway, which I’ll address in a moment.

Meanwhile, outside the Beltway, where real people (aka voters) live, there is little debate about the value of these programs. We like our Medicare and Medicaid—a lot. Republicans, independents and Democrats all feel this way, and by big, big majorities.

The Kaiser Family Foundation, which closely tracks Medicare developments, recently conducted an anniversary opinion poll. Here’s how the public responded:

*Keep Medicare intact. By two-to-one margins, people of all political persuasions favor preserving Medicare in its current form, as opposed to replacing it with vouchers or other forms of premium support.

Among people ages 65 and older, 85% of Republicans, 89% of independents, and 92% of Democrats say Medicare is very important. And roughly 90% of those using Medicare and Medicaid report positive experiences with the programs. While Medicaid was once viewed as health insurance for poor people, any stigma associated with the program has largely disappeared. If people need it, they’ll sign up for it, Kaiser said.

*Improve Medicare’s finances. People are concerned about the future of Medicare, and two-thirds of those surveyed support changing the program to make sure it’s around for future generations. Nearly 60% also support raising Medicare premiums for wealthier seniors. There was little support for raising the Medicare eligibility age or general cost increases for all beneficiaries.

By contrast, nearly nine in ten people want to empower Medicare to negotiate with drug companies over their prices, making it the most wisely supported financial reform. This move is expressly forbidden under the 2003 law that created Part D prescription drug insurance.

*Not enough coverage. Kaiser also found that nearly a third of Medicaid beneficiaries and more than 20% of those on Medicare reduced their use of dental, vision, and hearing care because they couldn’t afford them and the items were not covered by the programs.

Reforms on the way

While the public expects Medicare tomorrow to look much like it does today, the Centers for Medicare & Medicaid Services (CMS) has announced major reforms that will change the way healthcare providers are paid for their services. Instead of being reimbursed for based on the number of services or tests conducted, providers will increasingly be paid based on the quality of the work they do and on how well it helps improve patient health.

That policy is likely to include paying physicians to have conversations with patients about how they would want to be treated if they are too ill to express their wishes. Previous plans to encourage end-of-life discussions were derailed in 2009, when Sarah Palin denounced the plan as an effort to set up “death panels.” Today, with millions of boomers aging and more patients wanting a say in their own treatment, these policies have broad support.

At the same time, CMS is pushing providers to coordinate care for Medicare patients. Doctors, hospitals and other care providers will be expected to work together, and their compensation eventually will also be determined by patient outcomes and improved health.

Looking 50 years ahead

These reforms, while significant, are modest compared to the vision that Medicare’s creators had for the program 50 years ago. Back in 1965, Medicare was expected to be the first big step toward universal health care. As Jonathan Oberlander and Theodore R. Marmor write a new collection of 50th anniversary essays about the programs:

“They never imagined that, a half-century after its birth, Medicare would look as it does today, with seniors comprising the vast proportion of its enrollees. Medicare, they expected in 1965, would soon expand far past social insurance protection for the elderly and would evolve into a full-scale system of national health insurance for all Americans.”

There are many reasons why this did not come to pass. But perhaps the single most important factor was the Vietnam War, which soaked enormous sums from the federal budget and diverted the attention of Presidents Lyndon Johnson and Richard Nixon away from any serious efforts to expand Medicare as its creators had hoped.

Will Medicare ever grow into the broader health care program its creators envisioned? Today’s political gridlock makes that scenario unlikely. Of course, over the next decades, it’s possible that a new consensus will emerge that brings about a national health insurance program. But the American people will have to make it a priority. Let’s check back in 2065.

Philip Moeller is an expert on retirement, aging, and health. He is co-author of The New York Times bestseller, “Get What’s Yours: The Secrets to Maxing Out Your Social Security,” and is working on a companion book about Medicare. Reach him at moeller.philip@gmail.com or @PhilMoeller on Twitter.

Read next: Here’s What to Do When You’re Ready to Sign up for Medicare

TIME public health

Another Reason Why Women Should Avoid Douching

Women who use vaginal douches may have higher exposure to phthalates, a new study suggests

New research adds yet another reason to the list of why women should reconsider douching.

Douching—defined as the washing of the vagina with water or a fluid mixture—is widely discouraged by medical groups, including the U.S. Department of Health and Human Services (HHS). Medical experts say douching can lead to problems that range from infections to having trouble getting pregnant later on. Still, estimates show that about one in four women between ages 15 and 44 still do it.

Now, a new study published in the journal Environmental Health adds more evidence to the cautionary stance, showing that women who use douches can put themselves at a greater risk for exposure to harmful chemicals called phthalates, which are said to interfere with the body’s hormones.

MORE: Here’s The Staggering Healthcare Cost of Hormone-Disrupting Chemicals

Washing the vagina in the shower is not the same as douching. Often women use prepackaged mixes that are sold in stores containing water mixed with ingredients like vinegar, baking soda or iodine. Women then squirt the douche through a tube into the vagina. Doing so disrupts the healthy bacteria in the vagina as well as its natural acidity, HHS reports. If women already have an infection or sexually transmitted disease, douching could push that bacteria into the uterus, ovaries and fallopian tubes, where it can cause serious health issues.

The study authors report that phthalates can be found in a variety of personal care products, but that a particular kind called diethyl phthalate (DEP) can be found in items like douches or tampons. By assessing douching use and urine samples, the researchers found that compared to women who didn’t use douches, women who reported douching in the last month had 52% higher levels of urinary concentrations of a metabolite of DEP. Women who used douches two more more times in a month had 152% higher levels of the DEP metabolite in their urine.

MORE: Beauty Products May Trigger Early Menopause

The findings come from the researchers’ assessment of data from 739 women between the ages of 20 and 29 who were part of the National Health and Nutrition Examination Survey from 2001–2004. The women reported their use of feminine hygiene products like tampons, pads, vaginal douches, feminine spray, feminine powder and feminine wipes and had provided urine samples that were measured for metabolites of phthalates. Douches were the only product where researchers saw a significant link to higher levels of phthalates.

Study author Ami Zota, an assistant professor of environmental and occupational health at Milken Institute School of Public Health, says that since douches are used internally, they may introduce more opportunities for absorption. “There is already reason to be concerned about this practice,” she says. “Now we are saying there may be even more reason to be concerned because these chemicals are entering women’s bodies.”

Zota says data has linked phthalate chemicals to a wide range of health outcomes. “This includes reproductive problems for men and women as well as behavioral and developmental problems in babies due to exposure in the womb,” she says. The National Institutes of Health says that while the human health effects of phthalates aren’t yet fully known, they’re actively being studied by several government groups.

Notably, the researchers also showed that black women were likely at a greater risk, since their use of douches was much higher than other groups. The data shows that close to 40% of black women in the study said they used douches in the last month, compared to 14% of white women and 10% of Mexican American women. Zota says the reasons why women still use douches, despite widespread warnings against their use, are complex. “The literature suggests it involves a preference to feel fresh and clean and to remove menstrual blood and odors,” says Zota. “However social scientists as well as social justice advocates argue that societal forces may also be involved in why African American women in particular use vaginal douches, including pressures to conform to societal beauty norms and targeted advertising to the African American community.”

The researchers say this is one of the first studies to look at the link between feminine care products and chemical exposures in the human body, and that they hope it will become a larger area of research. “There is some research to suggest that these chemicals may be even more readily absorbed in the vagina than through our mouth,” says Zota. “It’s a really important issue, particularly for women’s health.”

TIME Health Care

8 in 10 Doctors Admit to Treating Patients While Sick

TIME.com stock photos Health First Aid Kit Gloves
Elizabeth Renstrom for TIME

Even while acknowledging that it can put patients at risk, according to a new survey.

A vast majority of healthcare workers acknowledged that they show up to work while feeling sick, even if they know it poses a risk to their patients, according to a new survey.

Medical professionals including physicians, registered nurse practitioners, physician assistants and midwives will work while they are under the weather, according to results from a small survey published Monday in the journal JAMA Pediatrics. Researchers surveyed over 530 attending physicians and advanced practice clinicians at a hospital and found that while 95.3% said they believed working while sick puts patients at risk, 83.1% had done it at least one time in the past year.

Most respondents said they would work while sick because they didn’t want to let their coworkers down. Others cited staffing concerns, not wanting to let down their patients or fear of being “ostracized” by their peers in the hospital.

The results come from one single hospital, so the findings may not apply to other medical offices. Still, the study authors conclude that the findings show an area of improvement for medical venues to both better protect patients and prevent health care worker burnout.

“Creating a safer and more equitable system of sick leave for health care workers requires a culture change in many institutions to decrease stigma—internal and external—associated with health care works illness,” reads a corresponding editorial. “Identifying solutions to prioritize patient safety must factor in workforce demands and variability in patient census to emphasize flexibility.”

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