NEW YORK (AP) —&nbsp;<a href="https://apnews.com/hub/donald-trump">Donald Trump</a>&nbsp;hosted a rally featuring crude and racist insults at New York’s Madison Square Garden Sunday, turning what his campaign had dubbed as the event where he would deliver his closing message into an illustration of what turns off his critics.

With just over a week before Election Day, speakers labeled Puerto Rico a “floating island of garbage,” called Democratic Vice President Kamala Harris “the devil,” and said the woman vying to become the first woman and Black woman president had begun her career as a prostitute.

“I don’t know if you guys know this, but there’s literally a floating island of garbage in the middle of the ocean right now. I think it’s called Puerto Rico,” said Tony Hinchcliffe, a stand-up comic whose set also included lewd and racist comments about Latinos, Jews and Black people, all key constituencies in the election just nine days away.

His joke was immediately criticized by Harris’ campaign as it competes with Trump to&nbsp;<a href="https://apnews.com/article/pennsylvania-latino-election-trump-harris-42afc4d9fe388923b713b45b94e0adcb">win over Puerto Rican communities</a>&nbsp;in Pennsylvania and other swing states.&nbsp;<a href="https://apnews.com/article/harris-bad-bunny-latino-vote-18ed2c1307264f2651ab4375d4b5070d">Puerto Rican music superstar Bad Bunny</a>&nbsp;endorsed Harris shortly after Hinchcliffe's appearance.

The normally pugnacious Trump campaign took the rare step of distancing itself from Hinchcliffe. “This joke does not reflect the views of President Trump or the campaign," senior adviser Danielle Alvarez said in a statement.

But other speakers also made incendiary comments. Trump’s childhood friend David Rem referred to Harris as “the Antichrist” and “the devil.” Businessman Grant Cardone told the crowd that Harris ”and her pimp handlers will destroy our country.”

The marquee event reflected the former president's tone throughout his third White House campaign. Though he refrained from doing so Sunday, Trump often tears into Harris in&nbsp;<a href="https://apnews.com/article/trump-kamala-lazy-trope-stereotype-4c2ded1046e492c5d24c7382245d0f7b">offensive and personal terms</a>&nbsp;himself, questioning in recent weeks her mental stability and her intelligence as well as calling her “lazy,” long a racist trope used against Black people.

The event was a surreal spectacle that included former professional wrestler Hulk Hogan, TV psychologist Dr. Phil McGraw, someone who painted a picture of Trump hugging the Empire State Building, and politicians including House Speaker Mike Johnson. At times, it felt like an amped-up version of the Republican National Convention in July that convened two days after Trump was nearly assassinated at a rally in Butler, Pennsylvania, which featured many of the same personalities — this time delivering speeches with far more volume.

And that was all before Trump was to take the stage, running more than two hours late.

After being introduced by his wife, Melania Trump, in a rare public appearance, the former president began by asking the same questions he’s asked at the start of every recent rally: “Are you better off now than you were four years ago?” The crowd responded with a resounding “No!”

“This election is a choice between whether we’ll have four more years of gross incompetence and failure, or whether we’ll begin the greatest years in the history of our country,” he said.

Trump announced a new tax credit for caregivers

Trump on Sunday added a new proposal to his list of tax cuts aimed at winning over older adults and blue-collar workers, which already includes vows to end taxes on Social Security benefits, tips and overtime pay: A tax credit for family caregivers.

This comes after Harris has talked about the “sandwich generation” of adults caring for aging parents while raising their children at the same time. Harris has proposed federal funding to cover home care costs for older Americans.

Trump otherwise repeated familiar lines about foreign policy and immigration, calling for the death penalty for any migrant who kills a U.S. citizen and saying that the day he takes office, “The migrant invasion of our country ends.”

As Trump’s remarks came up on an hour, some of the crowd began trickling out.

Tech mogul Elon Musk, who spoke earlier and introduced Melania Trump, was a prominent part of Trump’s closing campaign message. The former president called Musk “a genius” and “special.”

Musk nodded to Trump's recent plan to allow him to lead a government efficiency commission to audit the entire federal government. Several of Musk's businesses, including Tesla and SpaceX, have major government contracts or have relied on U.S. subsidies, and Musk has faced criticism after reports that he spoke privately in recent years with Russian President Vladimir Putin.

“Your money is being wasted and the department of government efficiency is going to fix that," Musk said before taking a place offstage beside Melania Trump.

The rally was an amped-up version of the RNC

Many of the speakers Sunday appeared on stage at the Republican National Convention. This time, the same speakers shouted and railed more against Democrats.

Hogan, returning to the venue where he performed years ago as a professional wrestler, seemed to reprise his character, emerging wearing a giant red, orange and yellow boa and violently waving a large American flag as he posed and danced. He spat on the stage during his speech, flexed his muscles repeatedly and told the audience: “Trump is the only man that can fix this country today.”

Some Democrats, arguing that Trump is a “fascist,” have compared his Sunday event to a&nbsp;<a href="https://apnews.com/article/trump-madison-square-garden-political-events-04c6f2d4e090c94cfdb1e949db82c532">pro-Nazi rally at the Garden</a>&nbsp;in February 1939. Several speakers on Sunday ripped Hillary Clinton, the Democrat defeated by Trump eight years ago, for saying recently that Trump would be “reenacting” the 1939 event.

“Hey guys, they’re now scrambling and trying to call us Nazis and fascists,” said Alina Habba, one of Trump’s attorneys, who draped a sparkly “MAGA” jacket over the lectern as she spoke. “And you know what they’re claiming, guys? It’s very scary. They’re claiming we’re going to go after them and try and put them in jail. Well, ain’t that rich?”

Declared Hogan in his characteristic raspy growl: “I don't see no stinkin' Nazis in here.”

Trump has denounced the four criminal indictments brought against him as politically motivated. He has&nbsp;<a href="https://apnews.com/article/donald-trump-enemies-from-within-5c4a34776469a55e71d3ba4d4e68cf62">ramped up</a>&nbsp;his denunciations in recent weeks of “enemies from within,” naming domestic political rivals, and suggested he would use the military to go after them. Harris, in turn, has&nbsp;<a href="https://apnews.com/article/fascism-meaning-harris-trump-kelly-fda56694feb1825dcf6477c8081a563d">called</a>&nbsp;Trump a “fascist.”

The arena was full hours before Trump was scheduled to speak. Outside the arena, the sidewalks were overflowing with Trump supporters in red “Make America Great Again” hats. There was a heavy security presence. Streets were blocked off and access to Penn Station was restricted.

In the crowd was Philip D’Agostino, a longtime Trump backer from Queens, the borough where Trump grew up. The 64-year-old said it was appropriate for Trump to be speaking at a place bills itself as “the world’s most famous arena.”

“It just goes to show ya that he has a bigger following of any man that has ever lived,” D'Agostino said.

New York has not voted for a Republican for president in 40 years. But that hasn't stopped Trump from continuing to insist he believes he can win.

Trump routinely uses his hometown as a foil before audiences in other states, painting a dark vision of the city that bears little resemblance to reality. He’s cast it as crime-ridden and overrun by violent, immigrant gangs who have taken over Fifth and Madison avenues and occupied Times Square.

Trump has a complicated history with the place where he built his business empire and that made him a tabloid and reality TV star. Its residents indicted him last year on 34 felony counts of falsifying business records. He was found guilty in that case, and also found liable in civil court for business fraud and sexual abuse.

On Sunday, however, Trump was much more complimentary of the city. He said “no city embodies the spirit” and energy of the American people more.

And as he concluded his speech after over an hour, opera singer Christopher Macchio came on stage to perform the song “New York, New York.”

The former president smiled and swayed slightly, his wife standing next to him on stage.

<figure>
 <img src="https://media.eaglewebservices.com/public/2024/10/1730061402605.png" alt="Image courtesy Margo Martin Deputy Director of Communications" />
 <figcaption>Image courtesy Margo Martin Deputy Director of Communications</figcaption>
 </figure>NEW YORK (AP) —&nbsp;<a href="https://apnews.com/hub/donald-trump">Donald Trump</a>&nbsp;hosted a rally featuring crude and racist insults at New York’s Madison Square Garden Sunday, turning what his campaign had dubbed as the event where he would deliver his closing message into an illustration of what turns off his critics.With just over a week before Election Day, speakers labeled Puerto Rico a “floating island of garbage,” called Democratic Vice President Kamala Harris “the devil,” and said the woman vying to become the first woman and Black woman president had begun her career as a prostitute.<figure>
 <img src="https://media.eaglewebservices.com/public/2024/10/1730074043797.png" alt="Image courtesy Margo Martin Deputy Director of Communications" />
 <figcaption>Image courtesy Margo Martin Deputy Director of Communications</figcaption>
 </figure>“I don’t know if you guys know this, but there’s literally a floating island of garbage in the middle of the ocean right now. I think it’s called Puerto Rico,” said Tony Hinchcliffe, a stand-up comic whose set also included lewd and racist comments about Latinos, Jews and Black people, all key constituencies in the election just nine days away.His joke was immediately criticized by Harris’ campaign as it competes with Trump to&nbsp;<a href="https://apnews.com/article/pennsylvania-latino-election-trump-harris-42afc4d9fe388923b713b45b94e0adcb">win over Puerto Rican communities</a>&nbsp;in Pennsylvania and other swing states.&nbsp;<a href="https://apnews.com/article/harris-bad-bunny-latino-vote-18ed2c1307264f2651ab4375d4b5070d">Puerto Rican music superstar Bad Bunny</a>&nbsp;endorsed Harris shortly after Hinchcliffe's appearance.The normally pugnacious Trump campaign took the rare step of distancing itself from Hinchcliffe. “This joke does not reflect the views of President Trump or the campaign," senior adviser Danielle Alvarez said in a statement.But other speakers also made incendiary comments. Trump’s childhood friend David Rem referred to Harris as “the Antichrist” and “the devil.” Businessman Grant Cardone told the crowd that Harris ”and her pimp handlers will destroy our country.”The marquee event reflected the former president's tone throughout his third White House campaign. Though he refrained from doing so Sunday, Trump often tears into Harris in&nbsp;<a href="https://apnews.com/article/trump-kamala-lazy-trope-stereotype-4c2ded1046e492c5d24c7382245d0f7b">offensive and personal terms</a>&nbsp;himself, questioning in recent weeks her mental stability and her intelligence as well as calling her “lazy,” long a racist trope used against Black people.The event was a surreal spectacle that included former professional wrestler Hulk Hogan, TV psychologist Dr. Phil McGraw, someone who painted a picture of Trump hugging the Empire State Building, and politicians including House Speaker Mike Johnson. At times, it felt like an amped-up version of the Republican National Convention in July that convened two days after Trump was nearly assassinated at a rally in Butler, Pennsylvania, which featured many of the same personalities — this time delivering speeches with far more volume.And that was all before Trump was to take the stage, running more than two hours late.After being introduced by his wife, Melania Trump, in a rare public appearance, the former president began by asking the same questions he’s asked at the start of every recent rally: “Are you better off now than you were four years ago?” The crowd responded with a resounding “No!”<div><blockquote class="twitter-tweet">President Trump x MSG 🇺🇸 <a href="https://t.co/DZT6E3ZnYC">pic.twitter.com/DZT6E3ZnYC</a>&mdash; Margo Martin (@margommartin) <a href="https://twitter.com/margommartin/status/1850692338051424429?ref_src=twsrc%5Etfw">October 28, 2024</a></blockquote> <script async src="https://platform.twitter.com/widgets.js" charset="utf-8"></script></div>“This election is a choice between whether we’ll have four more years of gross incompetence and failure, or whether we’ll begin the greatest years in the history of our country,” he said.<div><blockquote class="twitter-tweet">Former President Trump at Madison Square Garden rally: &quot;I&#39;m announcing a new policy today that I will support a tax credit for family care givers who take care of a parents or a loved one...I&#39;ll also make interest on car loans fully tax deductible, but only for cars made in… <a href="https://t.co/J1CI9XAHwt">pic.twitter.com/J1CI9XAHwt</a>&mdash; CSPAN (@cspan) <a href="https://twitter.com/cspan/status/1850723685453242420?ref_src=twsrc%5Etfw">October 28, 2024</a></blockquote> <script async src="https://platform.twitter.com/widgets.js" charset="utf-8"></script></div><h2>Trump announced a new tax credit for caregivers</h2>Trump on Sunday added a new proposal to his list of tax cuts aimed at winning over older adults and blue-collar workers, which already includes vows to end taxes on Social Security benefits, tips and overtime pay: A tax credit for family caregivers.This comes after Harris has talked about the “sandwich generation” of adults caring for aging parents while raising their children at the same time. Harris has proposed federal funding to cover home care costs for older Americans.Trump otherwise repeated familiar lines about foreign policy and immigration, calling for the death penalty for any migrant who kills a U.S. citizen and saying that the day he takes office, “The migrant invasion of our country ends.”As Trump’s remarks came up on an hour, some of the crowd began trickling out.Tech mogul Elon Musk, who spoke earlier and introduced Melania Trump, was a prominent part of Trump’s closing campaign message. The former president called Musk “a genius” and “special.”Musk nodded to Trump's recent plan to allow him to lead a government efficiency commission to audit the entire federal government. Several of Musk's businesses, including Tesla and SpaceX, have major government contracts or have relied on U.S. subsidies, and Musk has faced criticism after reports that he spoke privately in recent years with Russian President Vladimir Putin.“Your money is being wasted and the department of government efficiency is going to fix that," Musk said before taking a place offstage beside Melania Trump.<h2>The rally was an amped-up version of the RNC</h2>Many of the speakers Sunday appeared on stage at the Republican National Convention. This time, the same speakers shouted and railed more against Democrats.Hogan, returning to the venue where he performed years ago as a professional wrestler, seemed to reprise his character, emerging wearing a giant red, orange and yellow boa and violently waving a large American flag as he posed and danced. He spat on the stage during his speech, flexed his muscles repeatedly and told the audience: “Trump is the only man that can fix this country today.”Some Democrats, arguing that Trump is a “fascist,” have compared his Sunday event to a&nbsp;<a href="https://apnews.com/article/trump-madison-square-garden-political-events-04c6f2d4e090c94cfdb1e949db82c532">pro-Nazi rally at the Garden</a>&nbsp;in February 1939. Several speakers on Sunday ripped Hillary Clinton, the Democrat defeated by Trump eight years ago, for saying recently that Trump would be “reenacting” the 1939 event.“Hey guys, they’re now scrambling and trying to call us Nazis and fascists,” said Alina Habba, one of Trump’s attorneys, who draped a sparkly “MAGA” jacket over the lectern as she spoke. “And you know what they’re claiming, guys? It’s very scary. They’re claiming we’re going to go after them and try and put them in jail. Well, ain’t that rich?”Declared Hogan in his characteristic raspy growl: “I don't see no stinkin' Nazis in here.”Trump has denounced the four criminal indictments brought against him as politically motivated. He has&nbsp;<a href="https://apnews.com/article/donald-trump-enemies-from-within-5c4a34776469a55e71d3ba4d4e68cf62">ramped up</a>&nbsp;his denunciations in recent weeks of “enemies from within,” naming domestic political rivals, and suggested he would use the military to go after them. Harris, in turn, has&nbsp;<a href="https://apnews.com/article/fascism-meaning-harris-trump-kelly-fda56694feb1825dcf6477c8081a563d">called</a>&nbsp;Trump a “fascist.”The arena was full hours before Trump was scheduled to speak. Outside the arena, the sidewalks were overflowing with Trump supporters in red “Make America Great Again” hats. There was a heavy security presence. Streets were blocked off and access to Penn Station was restricted.In the crowd was Philip D’Agostino, a longtime Trump backer from Queens, the borough where Trump grew up. The 64-year-old said it was appropriate for Trump to be speaking at a place bills itself as “the world’s most famous arena.”“It just goes to show ya that he has a bigger following of any man that has ever lived,” D'Agostino said.<h2>A New Yorker returns home</h2>New York has not voted for a Republican for president in 40 years. But that hasn't stopped Trump from continuing to insist he believes he can win.Trump routinely uses his hometown as a foil before audiences in other states, painting a dark vision of the city that bears little resemblance to reality. He’s cast it as crime-ridden and overrun by violent, immigrant gangs who have taken over Fifth and Madison avenues and occupied Times Square.Trump has a complicated history with the place where he built his business empire and that made him a tabloid and reality TV star. Its residents indicted him last year on 34 felony counts of falsifying business records. He was found guilty in that case, and also found liable in civil court for business fraud and sexual abuse.On Sunday, however, Trump was much more complimentary of the city. He said “no city embodies the spirit” and energy of the American people more.And as he concluded his speech after over an hour, opera singer Christopher Macchio came on stage to perform the song “New York, New York.”The former president smiled and swayed slightly, his wife standing next to him on stage.

Trump's Madison Square Garden event featured controversial comments

PHILADELPHIA (AP) —&nbsp;<a href="https://apnews.com/hub/kamala-harris">Kamala Harris</a>&nbsp;said Sunday that “no one can sit on the sidelines” in this year's presidential election, capping a day of campaigning across the largest city in the crucial battleground state of Pennsylvania.

“We are focused on the future and we are focused on the needs of the American people," Harris said, "as opposed to Donald Trump, who spends full time looking in the mirror focused on himself.”

Speaking at a city recreation center, the Democratic vice president singled out young voters, praising them for being “rightly impatient for change," and told the audience that “there is too much at stake” in the campaign.

“We must not wake up the day after the election and have any regret about what we could have done in these next nine days," Harris said.

Mark Ruffalo and Don Cheadle, two actors who starred in Marvel's “Avengers” movies, were at the rally. Harris reminded the crowd that Pennsylvania's deadline for early voting is Tuesday, telling them to “get it done tomorrow if you can.”

Energizing voters in Philadelphia, a traditional Democratic stronghold, is crucial for Harris’ chances of beating Republican nominee Donald Trump. If turnout falls short here, she’ll struggle to overcome Trump’s advantages in Pennsylvania’s rural areas.

“Philadelphia is a very important part of our path to victory,” Harris told reporters. “It’s the reason I have been spending time here. But I’m feeling very optimistic about the enthusiasm.”

Kenny Payne, 62, said Harris is going to win and “it won’t be close.” The Democratic voter said he plays golf with a group of Republicans who say they won’t vote for Trump again.

“I think we’ll all be in bed by midnight,” he said outside the recreation center where Harris spoke.

Patrick Boe, 46, said he was confident about the city's enthusiasm for Harris, but he acknowledged that his view may be skewed.

Randyll Butler, a youth basketball coach who introduced Harris, said the election was in the “fourth quarter.”

“We cannot get tired," she said. "We cannot get complacent.”

The Democratic coalition relies on voters of color, and Harris’ itinerary on Sunday reflected that focus. She began the day with the Black congregation at the Church of Christian Compassion, where she said the United States is “determined to turn the page on hatred and division.”

Harris drew on the story of the Apostle Paul, who overcame difficulties to spread the word of Jesus.

“In hard times when we may grow weary in doing good, we must remember the power that works within us, the divine power that transformed Paul’s life, guided him through shipwreck and sustained him through trials,” Harris said.

W. Lonnie Herndon, the church’s senior pastor, introduced Harris as “the voice of the future” and followed her remarks with a sermon about compassion and how “strong people never put others down, they lift them up.”

“We are going to get out and vote,” he said as Harris listened from her seat in the front row. “And let me be crystal clear. We are not electing a pastor. We are electing a president that will deal with these divided United States, bring us back together.”

Her next stop was Philly Cuts, a barbershop in West Philadelphia. Pennsylvania state Rep. Jordan Harris moderated a conversation with Harris and Black men about improving racial representation in education. A poster of Barack Obama, the first Black president, was on the wall.

“We don’t pay teachers enough,” said Harris, who would be the second Black president and the first female president, if elected. “ Student loan debt is an issue.”

Outside the shop, people stood on stoops and lined the sidewalks in hopes of catching a glimpse of Harris. “The MVP of the White House!” someone shouted.

Harris visited nearby Hakim’s Bookstore, which specializes in African American history.

“It’s beautiful. It’s just so beautiful,” she said and asked to see good books for 6- and 8-year-old children, the same ages as her nieces.

Harris joked about her weight with Ann Hughes, the mother of Pennsylvania state Sen. Vincent Hughes.

“They’re working me to the bone,” she said.

After leaving the bookstore, Harris headed to a Puerto Rican restaurant named Freddy and Tony’s, where she thanked volunteers and told them “we are going to win.”

She also met with youth basketball players at the Alan Horowitz “Sixth Man” Center. The coach said the players are “student first, athlete second.” Harris told them to “think of your brain as a muscle and when you exercise it, it gets stronger.”

Harris has tried to keep the focus on abortion rights in the closing stretch of the campaign, including during appearances with&nbsp;<a href="https://apnews.com/article/kamala-harris-abortion-rights-2024-election-democrats-f228eedd3308dab2e1125fdf6029a4a2">Beyoncé</a>&nbsp;and&nbsp;<a href="https://apnews.com/article/harris-michelle-obama-biden-michigan-61897674ddc94706031d00aca5c1dc86">Michelle Obama</a>. In an interview with&nbsp;<a href="https://www.cbsnews.com/video/kamala-harris-on-her-first-priority-as-president/">CBS News</a>&nbsp;that aired Sunday, Harris declined to say whether she would support any restrictions on abortion, emphasizing the need to restore Roe v. Wade.

The nationwide right to abortion was overturned two years ago by the conservative majority on the Supreme Court that included three justices nominated by&nbsp;<a href="https://apnews.com/hub/donald-trump">Trump</a>&nbsp;while president.

“My first priority is to put back in place those protections and to stop this pain and to stop this injustice that is happening around our country,” Harris said.

She also brushed off Trump’s claim that he would not sign a national abortion ban if elected. “He says everything, come on,” Harris said. “Are we really taking his word for it?”

Harris and&nbsp;<a href="https://apnews.com/hub/tim-walz">Tim Walz</a>, the Minnesota governor who is her running mate, are expected to visit all seven battleground states in the coming days, part of a final blitz before the election.

While Harris was in Philadelphia on Sunday, Walz was campaigning in Las Vegas. On Monday, Walz will visit Manitowoc and Waukesha, Wisconsin, before joining Harris for a rally in Ann Arbor, Michigan, where the singer Maggie Rogers is scheduled to perform.

Harris will be in the nation's capital on Tuesday to deliver what her campaign calls&nbsp;<a href="https://apnews.com/article/kamala-harris-donald-trump-democracy-17bf55d6c22aba433588dcd1d1ad3105">her “closing argument”</a>&nbsp;in a speech from the Ellipse, a grassy space near the White House. It's the same place where Trump spoke on Jan. 6, 2021, when the Republican called on his supporters to march on the Capitol.

More campaign stops are scheduled in Georgia, North Carolina, Pennsylvania, Wisconsin, Nevada and Arizona.

<figure>
 <img src="https://media.eaglewebservices.com/public/2024/10/1730081169047.png" alt="Image courtesy CSPAN" />
 <figcaption>Image courtesy CSPAN</figcaption>
 </figure>PHILADELPHIA (AP) —&nbsp;<a href="https://apnews.com/hub/kamala-harris">Kamala Harris</a>&nbsp;said Sunday that “no one can sit on the sidelines” in this year's presidential election, capping a day of campaigning across the largest city in the crucial battleground state of Pennsylvania.“We are focused on the future and we are focused on the needs of the American people," Harris said, "as opposed to Donald Trump, who spends full time looking in the mirror focused on himself.”Speaking at a city recreation center, the Democratic vice president singled out young voters, praising them for being “rightly impatient for change," and told the audience that “there is too much at stake” in the campaign.“We must not wake up the day after the election and have any regret about what we could have done in these next nine days," Harris said.Mark Ruffalo and Don Cheadle, two actors who starred in Marvel's “Avengers” movies, were at the rally. Harris reminded the crowd that Pennsylvania's deadline for early voting is Tuesday, telling them to “get it done tomorrow if you can.”Energizing voters in Philadelphia, a traditional Democratic stronghold, is crucial for Harris’ chances of beating Republican nominee Donald Trump. If turnout falls short here, she’ll struggle to overcome Trump’s advantages in Pennsylvania’s rural areas.“Philadelphia is a very important part of our path to victory,” Harris told reporters. “It’s the reason I have been spending time here. But I’m feeling very optimistic about the enthusiasm.”Kenny Payne, 62, said Harris is going to win and “it won’t be close.” The Democratic voter said he plays golf with a group of Republicans who say they won’t vote for Trump again.“I think we’ll all be in bed by midnight,” he said outside the recreation center where Harris spoke.Patrick Boe, 46, said he was confident about the city's enthusiasm for Harris, but he acknowledged that his view may be skewed.“I’m in a bubble here,” Boe said.Randyll Butler, a youth basketball coach who introduced Harris, said the election was in the “fourth quarter.”“We cannot get tired," she said. "We cannot get complacent.”The Democratic coalition relies on voters of color, and Harris’ itinerary on Sunday reflected that focus. She began the day with the Black congregation at the Church of Christian Compassion, where she said the United States is “determined to turn the page on hatred and division.”Harris drew on the story of the Apostle Paul, who overcame difficulties to spread the word of Jesus.“In hard times when we may grow weary in doing good, we must remember the power that works within us, the divine power that transformed Paul’s life, guided him through shipwreck and sustained him through trials,” Harris said.W. Lonnie Herndon, the church’s senior pastor, introduced Harris as “the voice of the future” and followed her remarks with a sermon about compassion and how “strong people never put others down, they lift them up.”“We are going to get out and vote,” he said as Harris listened from her seat in the front row. “And let me be crystal clear. We are not electing a pastor. We are electing a president that will deal with these divided United States, bring us back together.”Her next stop was Philly Cuts, a barbershop in West Philadelphia. Pennsylvania state Rep. Jordan Harris moderated a conversation with Harris and Black men about improving racial representation in education. A poster of Barack Obama, the first Black president, was on the wall.“We don’t pay teachers enough,” said Harris, who would be the second Black president and the first female president, if elected. “ Student loan debt is an issue.”Outside the shop, people stood on stoops and lined the sidewalks in hopes of catching a glimpse of Harris. “The MVP of the White House!” someone shouted.Harris visited nearby Hakim’s Bookstore, which specializes in African American history.“It’s beautiful. It’s just so beautiful,” she said and asked to see good books for 6- and 8-year-old children, the same ages as her nieces.Harris joked about her weight with Ann Hughes, the mother of Pennsylvania state Sen. Vincent Hughes.“They’re working me to the bone,” she said.After leaving the bookstore, Harris headed to a Puerto Rican restaurant named Freddy and Tony’s, where she thanked volunteers and told them “we are going to win.”She also met with youth basketball players at the Alan Horowitz “Sixth Man” Center. The coach said the players are “student first, athlete second.” Harris told them to “think of your brain as a muscle and when you exercise it, it gets stronger.”Harris has tried to keep the focus on abortion rights in the closing stretch of the campaign, including during appearances with&nbsp;<a href="https://apnews.com/article/kamala-harris-abortion-rights-2024-election-democrats-f228eedd3308dab2e1125fdf6029a4a2">Beyoncé</a>&nbsp;and&nbsp;<a href="https://apnews.com/article/harris-michelle-obama-biden-michigan-61897674ddc94706031d00aca5c1dc86">Michelle Obama</a>. In an interview with&nbsp;<a href="https://www.cbsnews.com/video/kamala-harris-on-her-first-priority-as-president/">CBS News</a>&nbsp;that aired Sunday, Harris declined to say whether she would support any restrictions on abortion, emphasizing the need to restore Roe v. Wade.“It is that basic,” Harris said.The nationwide right to abortion was overturned two years ago by the conservative majority on the Supreme Court that included three justices nominated by&nbsp;<a href="https://apnews.com/hub/donald-trump">Trump</a>&nbsp;while president.“My first priority is to put back in place those protections and to stop this pain and to stop this injustice that is happening around our country,” Harris said.She also brushed off Trump’s claim that he would not sign a national abortion ban if elected. “He says everything, come on,” Harris said. “Are we really taking his word for it?”Harris and&nbsp;<a href="https://apnews.com/hub/tim-walz">Tim Walz</a>, the Minnesota governor who is her running mate, are expected to visit all seven battleground states in the coming days, part of a final blitz before the election.While Harris was in Philadelphia on Sunday, Walz was campaigning in Las Vegas. On Monday, Walz will visit Manitowoc and Waukesha, Wisconsin, before joining Harris for a rally in Ann Arbor, Michigan, where the singer Maggie Rogers is scheduled to perform.Harris will be in the nation's capital on Tuesday to deliver what her campaign calls&nbsp;<a href="https://apnews.com/article/kamala-harris-donald-trump-democracy-17bf55d6c22aba433588dcd1d1ad3105">her “closing argument”</a>&nbsp;in a speech from the Ellipse, a grassy space near the White House. It's the same place where Trump spoke on Jan. 6, 2021, when the Republican called on his supporters to march on the Capitol.More campaign stops are scheduled in Georgia, North Carolina, Pennsylvania, Wisconsin, Nevada and Arizona.___

Harris rallies  voters at barbershop, church, bookstore and basketball court

KANSAS CITY —As many as three people including two KCPD officers were injured in a multi-vehicle crash involving two marked Kansas City Police Department vehicles that occurred just before 5a.m. Sunday.

Police were dispatched originally to a collision on southbound 71 Highway, just before Bannister Road in Kansas City.&nbsp; First responders observed a black Dodge Charger wrecked out and abandoned, according KCPD Officer Alayna Gonzalez.

Police ordered a City Tow for the vehicle, and while waiting for the tow truck, a Ford Fusion came from behind and struck the rear of the KCPD Ford Explorer. 

This impact forced the Explorer forward, and into the rear of a second KCPD Ford Explorer. The second KCPD Explorer then traveled forward and struck the rear of the the abandoned Dodge Charger.&nbsp; &nbsp;Two officers were suffering from minor injuries, according to Officer Gonzalez and the driver of the Ford was transported to a hospital for treatment of serious injuries. Impairment is under consideration for the cause of the crash, according to Gonzalez.

KANSAS CITY —As many as three people including two KCPD officers were injured in a multi-vehicle crash involving two marked Kansas City Police Department vehicles that occurred just before 5a.m. Sunday.Police were dispatched originally to a collision on southbound 71 Highway, just before Bannister Road in Kansas City.&nbsp; First responders observed a black Dodge Charger wrecked out and abandoned, according KCPD Officer Alayna Gonzalez.Police ordered a City Tow for the vehicle, and while waiting for the tow truck, a Ford Fusion came from behind and struck the rear of the KCPD Ford Explorer. This impact forced the Explorer forward, and into the rear of a second KCPD Ford Explorer. The second KCPD Explorer then traveled forward and struck the rear of the the abandoned Dodge Charger.&nbsp; &nbsp;Two officers were suffering from minor injuries, according to Officer Gonzalez and the driver of the Ford was transported to a hospital for treatment of serious injuries. Impairment is under consideration for the cause of the crash, according to Gonzalez.

2 officers among in 3 injured in crash into marked KCPD vehicles

SEDGWICK COUNTY—A Kansas woman who died in an accident Saturday at a small airport has been identified as&nbsp;Amanda Gallagher, 37, of Wichita, according to an online fundraiser for her family.

<a href="https://www.gofundme.com/f/in-memory-of-amanda-gallagher-funeral-support">Click to view</a> the fundraiser

Just after 2:30 p.m. Saturday, emergency crews were alerted to the report of an accident at Cook Airfield, 6841 S. 143rd Street in Derby, according to the Sedgwick County Sheriff's office.&nbsp;

Gallagher was taking photos when she backed into an active airplane propeller. EMS transported her to a local hospital in extremely critical condition and she died of her injuries.

<figure>
 <img src="https://media.eaglewebservices.com/public/2024/10/1730074772543.png" alt="Amanda Gallagher&nbsp; photo GoFundMe" />
 <figcaption>Amanda Gallagher&nbsp; photo GoFundMe</figcaption>
 </figure>SEDGWICK COUNTY—A Kansas woman who died in an accident Saturday at a small airport has been identified as&nbsp;Amanda Gallagher, 37, of Wichita, according to an online fundraiser for her family.<a href="https://www.gofundme.com/f/in-memory-of-amanda-gallagher-funeral-support">Click to view</a> the fundraiserJust after 2:30 p.m. Saturday, emergency crews were alerted to the report of an accident at Cook Airfield, 6841 S. 143rd Street in Derby, according to the Sedgwick County Sheriff's office.&nbsp;Gallagher was taking photos when she backed into an active airplane propeller. EMS transported her to a local hospital in extremely critical condition and she died of her injuries.

Kansas woman dies after backing into airplane propellor 

KANSAS CITY – A Mexican national who worked with a drug-trafficking organization tied to the Cárteles Unidos cartel in Michoacán, Mexico, was convicted by a federal trial jury last week for his role in a $4.7 million conspiracy to distribute more than 335 kilograms of methamphetamine and 22 kilograms of heroin in the Kansas City metropolitan area and throughout the United States, according to the United State's Attorney.

Luis Eduardo Pineda-Zarao, 29, a citizen of Mexico residing in Lebanon, Tennessee, was found guilty of participating in a conspiracy to distribute methamphetamine and heroin from Feb. 28, 2020, to June 1, 2022.

The indictment alleges the conspiracy involved the distribution of more than 335.5 kilograms of methamphetamine, with an average street price of $300 per ounce, and more than 22.1 kilograms of heroin, with an average street price of $1,500 per ounce.

During the investigation, federal agents with Homeland Security Investigations conducted two undercover bulk cash pickups totaling $308,775 and seized $610,400 in bulk cash, over 56 kilograms of methamphetamine, 5.5 kilograms of heroin, 2.6 kilograms of marijuana, and at least eight firearms, two of which were stolen. Law enforcement officers also seized $277,863 during a vehicle stop and $114,863 while executing search warrants at four Kansas City, Mo., residences.

Pineda-Zarao is among 44 defendants charged in this case. Nine co-defendants have been sentenced and 34 co-defendants have pleaded guilty and await sentencing.

Following the presentation of evidence, the jury in the U.S. District Court in Kansas City, Mo., deliberated for less than an hour before returning guilty verdicts to U.S. District Judge Greg Kays, ending a trial that began Monday, Oct. 21.

Under federal statutes, Pineda-Zarao is subject to a mandatory minimum sentence of 10 years in federal prison without parole, up to a sentence of life in federal prison without parole. The maximum statutory sentence is prescribed by Congress and is provided here for informational purposes, as the sentencing of the defendant will be determined by the court based on the advisory sentencing guidelines and other statutory factors. A sentencing hearing will be scheduled after the completion of a presentence investigation by the United States Probation Office.

This case is being prosecuted by Assistant U.S. Attorneys Patrick C. Edwards and Megan Baker. It was investigated by Homeland Security Investigations, U.S. Customs and Border Protection, the Drug Enforcement Administration, the Jackson County Drug Task Force, IRS-Criminal Investigation, the Kansas Bureau of Investigation, the Kansas City, Mo., Police Department, the Kansas City, Kan., Police Department, the Missouri State Highway Patrol, the Kansas Highway Patrol, the Independence, Mo., Police Department, the Minnesota Bureau of Criminal Apprehension, the Minnesota State Patrol, the Olmsted County, Minn., Sheriff’s Office, the Texas Department of Public Safety, the FBI, the Clay County, Mo., Sheriff’s Department, the Bureau of Alcohol, Tobacco, Firearms and Explosives, and the U.S. Marshals Service.

Organized Crime and Drug Enforcement Task Force

This case is part of an Organized Crime Drug Enforcement Task Forces (OCDETF) operation. OCDETF identifies, disrupts, and dismantles the highest-level criminal organizations that threaten the United States using a prosecutor-led, intelligence-driven, multi-agency approach. Additional information about the OCDETF Program can be found at https://www.justice.gov/OCDETF.

This prosecution was brought as a part of the Department of Justice’s Organized Crime Drug Enforcement Task Forces (OCDETF) Co-located Strike Forces Initiative, which provides for the establishment of permanent multi-agency task force teams that work side-by-side in the same location. This co-located model enables agents from different agencies to collaborate on intelligence-driven, multi-jurisdictional operations against a continuum of priority targets and their affiliate illicit financial networks. These prosecutor-led co-located Strike Forces capitalize on the synergy created through the long-term relationships that can be forged by agents, analysts, and prosecutors who remain together over time, and they epitomize the model that has proven most effective in combating organized crime. The principal mission of the OCDETF program is to identify, disrupt, and dismantle the most serious drug trafficking organizations, transnational criminal organizations, and money laundering organizations that present a significant threat to the public safety, economic, or national security of the United States.

KANSAS CITY – A Mexican national who worked with a drug-trafficking organization tied to the Cárteles Unidos cartel in Michoacán, Mexico, was convicted by a federal trial jury last week for his role in a $4.7 million conspiracy to distribute more than 335 kilograms of methamphetamine and 22 kilograms of heroin in the Kansas City metropolitan area and throughout the United States, according to the United State's Attorney.Luis Eduardo Pineda-Zarao, 29, a citizen of Mexico residing in Lebanon, Tennessee, was found guilty of participating in a conspiracy to distribute methamphetamine and heroin from Feb. 28, 2020, to June 1, 2022.The indictment alleges the conspiracy involved the distribution of more than 335.5 kilograms of methamphetamine, with an average street price of $300 per ounce, and more than 22.1 kilograms of heroin, with an average street price of $1,500 per ounce.During the investigation, federal agents with Homeland Security Investigations conducted two undercover bulk cash pickups totaling $308,775 and seized $610,400 in bulk cash, over 56 kilograms of methamphetamine, 5.5 kilograms of heroin, 2.6 kilograms of marijuana, and at least eight firearms, two of which were stolen. Law enforcement officers also seized $277,863 during a vehicle stop and $114,863 while executing search warrants at four Kansas City, Mo., residences.Pineda-Zarao is among 44 defendants charged in this case. Nine co-defendants have been sentenced and 34 co-defendants have pleaded guilty and await sentencing.Following the presentation of evidence, the jury in the U.S. District Court in Kansas City, Mo., deliberated for less than an hour before returning guilty verdicts to U.S. District Judge Greg Kays, ending a trial that began Monday, Oct. 21.Under federal statutes, Pineda-Zarao is subject to a mandatory minimum sentence of 10 years in federal prison without parole, up to a sentence of life in federal prison without parole. The maximum statutory sentence is prescribed by Congress and is provided here for informational purposes, as the sentencing of the defendant will be determined by the court based on the advisory sentencing guidelines and other statutory factors. A sentencing hearing will be scheduled after the completion of a presentence investigation by the United States Probation Office.This case is being prosecuted by Assistant U.S. Attorneys Patrick C. Edwards and Megan Baker. It was investigated by Homeland Security Investigations, U.S. Customs and Border Protection, the Drug Enforcement Administration, the Jackson County Drug Task Force, IRS-Criminal Investigation, the Kansas Bureau of Investigation, the Kansas City, Mo., Police Department, the Kansas City, Kan., Police Department, the Missouri State Highway Patrol, the Kansas Highway Patrol, the Independence, Mo., Police Department, the Minnesota Bureau of Criminal Apprehension, the Minnesota State Patrol, the Olmsted County, Minn., Sheriff’s Office, the Texas Department of Public Safety, the FBI, the Clay County, Mo., Sheriff’s Department, the Bureau of Alcohol, Tobacco, Firearms and Explosives, and the U.S. Marshals Service.Organized Crime and Drug Enforcement Task ForceThis case is part of an Organized Crime Drug Enforcement Task Forces (OCDETF) operation. OCDETF identifies, disrupts, and dismantles the highest-level criminal organizations that threaten the United States using a prosecutor-led, intelligence-driven, multi-agency approach. Additional information about the OCDETF Program can be found at https://www.justice.gov/OCDETF.KC Metro Strike ForceThis prosecution was brought as a part of the Department of Justice’s Organized Crime Drug Enforcement Task Forces (OCDETF) Co-located Strike Forces Initiative, which provides for the establishment of permanent multi-agency task force teams that work side-by-side in the same location. This co-located model enables agents from different agencies to collaborate on intelligence-driven, multi-jurisdictional operations against a continuum of priority targets and their affiliate illicit financial networks. These prosecutor-led co-located Strike Forces capitalize on the synergy created through the long-term relationships that can be forged by agents, analysts, and prosecutors who remain together over time, and they epitomize the model that has proven most effective in combating organized crime. The principal mission of the OCDETF program is to identify, disrupt, and dismantle the most serious drug trafficking organizations, transnational criminal organizations, and money laundering organizations that present a significant threat to the public safety, economic, or national security of the United States.

Jury: Mexican national guilty of $4.7 million meth, heroin conspiracy in KC

KANSAS CITY —Two people died in an accident just before 4a.m. Sunday in Kansas City.

A Dodge Hornet was&nbsp; southbound on Jackson Avenue in Kansas City at a very high rate of speed, according to KCPD Officer Alayna Gonzalez. The driver of the Dodge failed to stop for the red traffic control signal at Truman Road.

The Dodge struck the left side of an eastbound Ford Fusion that was traveling through the green light. The impact forced the Ford to the south where it impacted a wooden utility pole. The Dodge continued southeast after the crash and struck the west wall of the business, Cash America Pawn at 4205 Truman Road.

The front passenger of the Dodge and the driver of the Ford were pronounced dead at the scene. The driver and two additional passengers of the Dodge were transported to area hospitals with non-life-threatening injuries. Impairment is under investigation for the driver of the Dodge, according to Gonzalez&nbsp;

KANSAS CITY —Two people died in an accident just before 4a.m. Sunday in Kansas City.A Dodge Hornet was&nbsp; southbound on Jackson Avenue in Kansas City at a very high rate of speed, according to KCPD Officer Alayna Gonzalez. The driver of the Dodge failed to stop for the red traffic control signal at Truman Road.The Dodge struck the left side of an eastbound Ford Fusion that was traveling through the green light. The impact forced the Ford to the south where it impacted a wooden utility pole. The Dodge continued southeast after the crash and struck the west wall of the business, Cash America Pawn at 4205 Truman Road.The front passenger of the Dodge and the driver of the Ford were pronounced dead at the scene. The driver and two additional passengers of the Dodge were transported to area hospitals with non-life-threatening injuries. Impairment is under investigation for the driver of the Dodge, according to Gonzalez&nbsp;

KCPD: Impairment a possible factor in crash that left 2 dead

Son of first woman on U.S. Supreme Court reflects on O’Connor’s journey

BY:&nbsp;<a href="https://kansasreflector.com/author/tim-carpenter/">TIM CARPENTER</a> <a href="https://kansasreflector.com/">Kansas Reflector</a>

LAWRENCE — The late Sandra Day O’Connor overcame stifling 1950s-era gender barriers widely imposed on law school graduates to build a career culminating with appointment as the first woman to serve on the U.S. Supreme Court.

The list of rejections received by the Stanford University graduate included the influential California firm of Gibson, Dunn and Crutcher that employed William French Smith, who decades later became U.S. attorney general under President Ronald Reagan. One of Reagan’s campaign promises was to appoint a woman to the Supreme Court.

Ironically, it was Smith who dispatched a Justice Department attorney, Ken Starr, to conduct the pre-nomination interview with O’Connor in the living room of her Arizona home in 1981.

“Smith’s law firm in Los Angeles that he left to become attorney general was one of the firms that turned mom down, but offered her a job as a legal secretary,” said Scott O’Connor, the late justice’s eldest son. “So, during the interview she got to really twist the knife.”

Reagan nominated O’Connor and, despite conservative backlash tied to abortion politics and gender bias, she won unanimous confirmation in the U.S. Senate. She served on the nation’s highest court for 24 years, wrote more than 600 opinions and was viewed as a swing vote on a divided court. She retired in 2006 and passed away in December 2023.

On Thursday, the Robert Dole Institute of Politics at the University of Kansas presented the late justice with the $25,000 Dole Leadership Prize. It’s a bipartisan award presented to individuals or nonprofits engaged in public service that demonstrated the importance of engaging in political and civic affairs. She was the Dole Institute’s first posthumous recipient.

Other recipients include Presidents George H.W. Bush and Bill Clinton, civil rights leader and U.S. Rep. John Lewis, Secretary of State James Baker, U.S. Sen. Nancy Kassebaum and professor Temple Grandin.

In terms of Justice O’Connor, the award honored her service in all three branches of Arizona government, her prominent role on the U.S. Supreme Court and her dedication in retirement to the nonprofit organization iCivics. It’s an educational program offering millions of students annually the opportunity to engage in civics.

“She was the quintessential American,” said Scott O’Connor, who accepted the prize on behalf of his mother. “She understood our country. What it could be. She respected its institutions and felt it was our obligation to do all we could do to make them function better, not to tear them apart.”

He said her selection by Reagan demonstrated that anyone could reach the highest echelon of U.S. government if qualified and passionate for the work. She grew up on a family cattle ranch about 9 miles from the nearest paved road in a home without running water until she was age 7. She enrolled at Stanford at 16 and earned a law degree by 21.

Her legal career began in San Mateo, California, where she served as a county attorney without a salary. She shared a desk with a receptionist. Her husband, attorney John Jay O’Connor, was drafted and both worked for the military in Germany for three years before returning to the United States and moving to Maricopa County, Arizona.

She left private practice in the late 1960s to become an assistant attorney general in Arizona. For a portion of that time, O’Connor and another woman in the office worked three-fourths time for one-half pay while raising young children.

O’Connor was subsequently appointed to a vacancy in the Arizona Senate and over two-plus terms became the first woman to serve as a Senate majority leader of any state.

“She enjoyed the work,” Scott O’Connor said. “It was extremely challenging, but she soon realized the typical state legislator wasn’t necessarily the most ethical, the most high-minded person you might want to spend the rest of your career with.”

The Republican chose not to seek reelection to the state Senate. She served for four years on the Maricopa County Superior Court prior to appointment by the governor to the Arizona Court of Appeals. She was on the state appellate bench until nominated by Reagan in 1981.

“All of that happened to a little ranch girl from the middle of nowhere,” Scott O’Connor said. “It was just astonishing. It gave our family great hope for America — that it works.”

Scott O’Connor said the life experiences of his mother — a childhood on a cattle ranch, breaking gender barriers, serving in the three branches of government — offered an awareness of American life not shared enough by modern appointees to the federal judiciary. He said too many federal judges “come through a cloistered existence.”

“They don’t know what it’s like to pass a bill that is controversial,” he said. “They don’t know what it’s like to run for public office. They don’t know necessarily what it’s like to represent the poorest indigent clients in a strip-mall law office.”

<figure>
 <img src="https://media.eaglewebservices.com/public/2024/10/1730039502163.png" alt="Scott O’Connor, eldest son of the late U.S. Supreme Court Justice Sandra Day O’Connor, accepted the Dole Leadership Prize from the Dole Institute at University of Kansas. It honors individuals and nonprofits dedicated to inspiring discourse in political or civic life. A bust of the late U.S. Sen. Robert Dole sits over his left shoulder. (Kansas Reflector screen capture from Dole Institute)" />
 <figcaption>Scott O’Connor, eldest son of the late U.S. Supreme Court Justice Sandra Day O’Connor, accepted the Dole Leadership Prize from the Dole Institute at University of Kansas. It honors individuals and nonprofits dedicated to inspiring discourse in political or civic life. A bust of the late U.S. Sen. Robert Dole sits over his left shoulder. (Kansas Reflector screen capture from Dole Institute)</figcaption>
 </figure><h2>Son of first woman on U.S. Supreme Court reflects on O’Connor’s journey</h2>BY:&nbsp;<a href="https://kansasreflector.com/author/tim-carpenter/">TIM CARPENTER</a> <a href="https://kansasreflector.com/">Kansas Reflector</a>LAWRENCE — The late Sandra Day O’Connor overcame stifling 1950s-era gender barriers widely imposed on law school graduates to build a career culminating with appointment as the first woman to serve on the U.S. Supreme Court.The list of rejections received by the Stanford University graduate included the influential California firm of Gibson, Dunn and Crutcher that employed William French Smith, who decades later became U.S. attorney general under President Ronald Reagan. One of Reagan’s campaign promises was to appoint a woman to the Supreme Court.Ironically, it was Smith who dispatched a Justice Department attorney, Ken Starr, to conduct the pre-nomination interview with O’Connor in the living room of her Arizona home in 1981.“Smith’s law firm in Los Angeles that he left to become attorney general was one of the firms that turned mom down, but offered her a job as a legal secretary,” said Scott O’Connor, the late justice’s eldest son. “So, during the interview she got to really twist the knife.”Reagan nominated O’Connor and, despite conservative backlash tied to abortion politics and gender bias, she won unanimous confirmation in the U.S. Senate. She served on the nation’s highest court for 24 years, wrote more than 600 opinions and was viewed as a swing vote on a divided court. She retired in 2006 and passed away in December 2023.On Thursday, the Robert Dole Institute of Politics at the University of Kansas presented the late justice with the $25,000 Dole Leadership Prize. It’s a bipartisan award presented to individuals or nonprofits engaged in public service that demonstrated the importance of engaging in political and civic affairs. She was the Dole Institute’s first posthumous recipient.Other recipients include Presidents George H.W. Bush and Bill Clinton, civil rights leader and U.S. Rep. John Lewis, Secretary of State James Baker, U.S. Sen. Nancy Kassebaum and professor Temple Grandin.In terms of Justice O’Connor, the award honored her service in all three branches of Arizona government, her prominent role on the U.S. Supreme Court and her dedication in retirement to the nonprofit organization iCivics. It’s an educational program offering millions of students annually the opportunity to engage in civics.“She was the quintessential American,” said Scott O’Connor, who accepted the prize on behalf of his mother. “She understood our country. What it could be. She respected its institutions and felt it was our obligation to do all we could do to make them function better, not to tear them apart.”He said her selection by Reagan demonstrated that anyone could reach the highest echelon of U.S. government if qualified and passionate for the work. She grew up on a family cattle ranch about 9 miles from the nearest paved road in a home without running water until she was age 7. She enrolled at Stanford at 16 and earned a law degree by 21.Her legal career began in San Mateo, California, where she served as a county attorney without a salary. She shared a desk with a receptionist. Her husband, attorney John Jay O’Connor, was drafted and both worked for the military in Germany for three years before returning to the United States and moving to Maricopa County, Arizona.She left private practice in the late 1960s to become an assistant attorney general in Arizona. For a portion of that time, O’Connor and another woman in the office worked three-fourths time for one-half pay while raising young children.O’Connor was subsequently appointed to a vacancy in the Arizona Senate and over two-plus terms became the first woman to serve as a Senate majority leader of any state.“She enjoyed the work,” Scott O’Connor said. “It was extremely challenging, but she soon realized the typical state legislator wasn’t necessarily the most ethical, the most high-minded person you might want to spend the rest of your career with.”The Republican chose not to seek reelection to the state Senate. She served for four years on the Maricopa County Superior Court prior to appointment by the governor to the Arizona Court of Appeals. She was on the state appellate bench until nominated by Reagan in 1981.“All of that happened to a little ranch girl from the middle of nowhere,” Scott O’Connor said. “It was just astonishing. It gave our family great hope for America — that it works.”Scott O’Connor said the life experiences of his mother — a childhood on a cattle ranch, breaking gender barriers, serving in the three branches of government — offered an awareness of American life not shared enough by modern appointees to the federal judiciary. He said too many federal judges “come through a cloistered existence.”“They don’t know what it’s like to pass a bill that is controversial,” he said. “They don’t know what it’s like to run for public office. They don’t know necessarily what it’s like to represent the poorest indigent clients in a strip-mall law office.”

Dole leadership prize honors life of the late Sandra Day O’Connor, a ‘quintessential American’

Experts worry older patients could be exposed to ‘catastrophic’ costs and interrupted access to care.

BY:&nbsp;<a href="https://stateline.org/author/avollers/">ANNA CLAIRE VOLLERS</a> <a href="https://stateline.org/">Stateline</a>

HUNTSVILLE, Ala. — Libby and Andrew Potter usually ignore the avalanche of Medicare Advantage ads that land in the mailbox at their home in Huntsville, Alabama, each fall as Medicare’s open enrollment period begins.

Libby, a retired middle school librarian, has what she considers good health insurance through the state employee health plan. Andrew has insurance through his job as a university professor and plans to join Libby’s insurance when he retires next year.

But this year, a few days before open enrollment began, a letter arrived from UnitedHealthcare, informing the Potters that the region’s largest hospital system would no longer be considered in-network for Libby’s Medicare Advantage plan.

The Potters spent the next couple of weeks worried and unsure what to do. It seemed incredible that 14 area hospitals, including the area’s only Level 1 trauma center, could suddenly become much, much more expensive.

“We were being very careful in how we go up and down stairs,” Libby joked.

Medicare is the federal health insurance program for people over 65 and those with certain disabilities. Medicare Advantage is a version of Medicare run by private insurance companies that contract with the government. These plans typically offer extra benefits, such as dental, vision and prescription drug coverage, that aren’t included with traditional Medicare.&nbsp;<a href="https://www.medpac.gov/wp-content/uploads/2024/03/Mar24_Ch12_MedPAC_Report_To_Congress_SEC.pdf" target="_blank">More than half</a>&nbsp;of eligible Medicare beneficiaries now get their coverage through private Medicare Advantage plans.

But this year, as Medicare’s open enrollment season kicks off, more than 1 million patients will have to shop for new health insurance. Facing financial and federal regulatory pressures, many insurers are pulling their Medicare Advantage plans from counties and states they’ve deemed unprofitable. Meanwhile, large health systems in states including Alabama, Minnesota and Vermont have cut ties with some Medicare Advantage plans.

It’s a situation that’s alarmed state insurance regulators, who are fielding questions from older adults concerned about their hospitals and doctors withdrawing from their Medicare Advantage plans. Last month, the National Association of Insurance Commissioners sent&nbsp;<a href="https://content.naic.org/sites/default/files/inline-files/FINAL%20MA%20SEP%20CMS%20Letter%20Sept%202024.pdf" target="_blank">a letter</a>&nbsp;to the federal Centers for Medicare &amp; Medicaid Services asking for guidance.

“Beneficiaries are faced with either paying the increased out-of-network costs or rescheduling their necessary medical services with another provider who may not have prompt availability,” the insurance commissioners’ group wrote. “A delay in access to medically necessary services is likely to result in harm.”

The Potters eventually learned that Libby’s copayments at the hospital would remain the same whether or not the hospital was in-network for the state educators’ Medicare Advantage plan. But those with other UnitedHealthcare Medicare Advantage plans will have to pay more — or find another plan.

“When a contract leaves the market, that can threaten continuity of care and access to care,” said Dr. Amal Trivedi, professor of health services, policy and practice at the Brown University School of Public Health. “The beneficiary will have to choose a new plan, and each of these plans is going to have a different benefit structure, different provider network, different prior authorization policies and different [prescription drug] formularies.

“The worry is that’s going to affect their out-of-pocket costs, expose them to catastrophic spending, or compromise their access to care.”

Insurance giants such as UnitedHealthcare have been aggressively pushing enrollment in their Medicaid Advantage plans for the past several years, luring customers with perks and bonuses not available through traditional Medicare. These plans tend to have low or even no monthly premiums and offer extra benefits such as vision and dental coverage, gym memberships, transportation to medical appointments, and even debit cards for medical supplies.

And they’re simple: They provide all of a person’s coverage in one plan, unlike traditional Medicare, under which people must get separate prescription drug coverage and supplemental coverage.

But there are trade-offs. Medicare Advantage plans often have a limited network of hospitals and physicians. And while the premiums are typically low, enrollees could end up&nbsp;<a href="https://www.ncoa.org/article/what-is-the-difference-between-medicare-advantage-and-medigap/#:~:text=You%20could%20end,with%20Original%20Medicare)." target="_blank">paying more in the long run</a>&nbsp;in copays and deductibles if they develop a serious illness.

Medicare Advantage programs also are&nbsp;<a href="https://www.kff.org/medicare/issue-brief/use-of-prior-authorization-in-medicare-advantage-exceeded-46-million-requests-in-2022/#:~:text=Virtually%20all%20enrollees%20in%20Medicare%20Advantage%20(99%25)%20are%20required%20to%20obtain%20prior%20authorization%20for%20some%20services%20%E2%80%93%20most%20commonly%2C%20higher%20cost%20services%2C%20such%20as%20inpatient%20hospital%20stays%2C%20skilled%20nursing%20facility%20stays%2C%20and%20chemotherapy.%20This%20contrasts%20with%20traditional%20Medicare" target="_blank">more likely than traditional Medicare</a>&nbsp;to require prior authorization for hospital stays and other high-cost services. The plans’ prior authorization requirements have&nbsp;<a href="https://www.nytimes.com/2024/05/25/science/medicare-seniors-authorization.html" target="_blank">prompted increased scrutiny</a>&nbsp;in recent years. A congressional investigation by Democratic Senate staff released this month, for example, found the nation’s largest Medicare Advantage insurers&nbsp;<a href="https://www.hsgac.senate.gov/wp-content/uploads/2024.10.17-PSI-Majority-Staff-Report-on-Medicare-Advantage.pdf" target="_blank">denied a quarter of all prior authorization requests</a>&nbsp;for post-acute care in nursing homes, rehab hospitals and long-term care.

Medicare Advantage is popular among large employers, many of which are&nbsp;<a href="https://www.kff.org/medicare/issue-brief/10-reasons-why-medicare-advantage-enrollment-is-growing-and-why-it-matters/#:~:text=A%20growing%20share%20of%20large%20employers%20are%20shifting%20their%20Medicare%2Dage%20retirees%20into%20Medicare%20Advantage%20plans%20for%20both%20Medicare%20and%20supplemental%20benefits" target="_blank">shifting their Medicare-age retirees</a>&nbsp;into these plans. And&nbsp;<a href="https://www.kff.org/medicare/issue-brief/in-2024-a-majority-of-states-offer-medicare-advantage-plans-to-their-state-retirees-with-13-offering-medicare-advantage-exclusively/" target="_blank">most states</a>&nbsp;offer Medicare Advantage plans to retired state employees; in 13 states, it’s the only option. In some of those 13 states, retirees forfeit their health benefits in perpetuity if they choose coverage under traditional Medicare.

North Carolina Treasurer Dale Folwell, whose office administers the state health plan, said its Medicare Advantage plan is popular.

“What we hear from our retirees, is that they are grateful and happy to have such a great offering as a result of their retirement benefit,” the Republican said. “That’s why nearly 89% of our retirees over age 65 have availed themselves of the [Medicare Advantage] product we offer them.”

This year, the handful of insurance giants that dominate the Medicare Advantage market have said they’re scaling back or eliminating plans, to shed members and boost sagging profits. They&nbsp;<a href="https://s2.q4cdn.com/447711729/files/doc_financials/2024/q1/CVS-1Q24-Earnings-Transcript.pdf" target="_blank">blame</a>&nbsp;new federal changes to their reimbursements, including&nbsp;<a href="https://www.axios.com/2024/04/02/medicare-advantage-insurer-pay" target="_blank">a small cut to their base payments</a>, and say patients are using more medical services and benefits than they anticipated.

Though most companies haven’t released data on specific counties where they’re making cuts, plans are reportedly shuttering in states such as&nbsp;<a href="https://pfsinsurance.com/news/wellcare-080524" target="_blank">Alabama</a>,&nbsp;<a href="https://pfsinsurance.com/news/wellcare-080524" target="_blank">Massachusetts</a>,&nbsp;<a href="https://www.beckerspayer.com/payer/bcbs-kansas-city-exiting-medicare-advantage-market.html" target="_blank">Missouri</a>,&nbsp;<a href="https://www.concordmonitor.com/harvard-pilgrim-medicare-new-hampshire-57353658" target="_blank">New Hampshire</a>,&nbsp;<a href="https://pfsinsurance.com/news/wellcare-080524" target="_blank">New Mexico</a>,&nbsp;<a href="https://www.dmagazine.com/healthcare-business/2024/09/southwestern-health-resources-to-sunset-medicare-advantage-health-plan-amid-layoffs/" target="_blank">Texas</a>&nbsp;and&nbsp;<a href="https://vtdigger.org/2024/10/03/2-medicare-advantage-plans-will-no-longer-be-available-in-vermont-in-2025/" target="_blank">Vermont</a>, affecting hundreds of thousands of older adults. Experts say the reasons why a company might find certain markets unprofitable are complex, but can include demographics, availability of providers and plans that are already in the market.

“[T]he industry broadly is going to be trimming benefits and in some cases significantly, and exiting from certain counties that aren’t profitable,” Aetna’s former President Brian Kane&nbsp;<a href="https://s2.q4cdn.com/447711729/files/doc_financials/2024/q1/CVS-1Q24-Earnings-Transcript.pdf" target="_blank">told shareholders</a>&nbsp;on an earnings call in May, before he left his position. Aetna, a subsidiary of CVS Health, is the third-largest Medicare Advantage insurer in the nation. “I think that’s an industry issue and I think it’s clearly an Aetna focus as well.”

Executives at CVS Health, Aetna’s parent company, told shareholders the priority for its Medicare Advantage program would be improving profit margins rather than increasing the number of enrollees.

They have not announced publicly which counties will lose Medicare Advantage plans, but noted their changes could&nbsp;<a href="https://www.statnews.com/2024/05/14/cvs-aetna-medicare-advantage-cut-benefits/?utm_campaign=health_care_inc&amp;utm_medium=email&amp;_hsenc=p2ANqtz-_KG6jNdcCYt_b2-JXr0SMQbogbV_XDMgmCvnUjnWW5m_UsBvalMlvUPozxIsPXvn9C126pFPAlA2qO2jZszULKf47ccg&amp;_hsmi=307746331&amp;utm_content=307746331&amp;utm_source=hs_email" target="_blank">push out 10% of their membership</a>, meaning up to 420,000 patients could be forced to shop for a different plan.

Even with the decline in the number of plans available next year, “there are still a lot of plans and people have a lot of options,” said Jeannie Fuglesten Biniek, associate director of the Medicare policy program at KFF, a health policy research organization. Next year, the average Medicare beneficiary will have access to 34 Medicare Advantage plans that include drug coverage, down from 36 this year, she said.

But that average masks wide variation across states and even counties in how many plans are available.

“There are a handful of counties, more than in previous years, where all Medicare Advantage plans exited and those look to be predominantly rural counties,” said Fuglesten Biniek. “We’re talking fortyish counties out of 3,000. For those people in those counties, that matters, but overall, it’s a smaller number.”

Experts say there isn’t enough data available yet to know whether the plan exits are concentrated in certain states or counties.

But research has shown that Medicare Advantage plans that enroll higher shares of Black beneficiaries are&nbsp;<a href="https://jamanetwork.com/journals/jama-health-forum/fullarticle/2797677#:~:text=enrolled%20a%20greater%20proportion%20of%20Black%20(21.9%25%20vs%2014.3%25%2C%20P%E2%80%89%3C%E2%80%89.001)%20beneficiaries" target="_blank">more likely to be terminated</a>, said Trivedi, of Brown University. Black enrollees have&nbsp;<a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/1475-6773.13977" target="_blank">more lower-quality Medicare Advantage plans</a>&nbsp;available in their counties of residence than white enrollees, research shows; terminated contracts tend to&nbsp;<a href="https://jamanetwork.com/journals/jama-health-forum/fullarticle/2797677#:~:text=Terminated%20contracts%20tended%20to%20have%20lower%20quality" target="_blank">have lower-quality ratings</a>.

“The consequence is that contract terminations in Medicare Advantage seem to have a disproportionate effect on Black beneficiaries because their contracts are more likely to be terminated,” Trivedi said.

A&nbsp;<a href="https://www.kff.org/medicare/report/disparities-in-health-measures-by-race-and-ethnicity-among-beneficiaries-in-medicare-advantage-a-review-of-the-literature/" target="_blank">disproportionate share</a>&nbsp;of Medicare Advantage beneficiaries are Black, Hispanic, and Asian and Pacific Islander. These patients&nbsp;<a href="https://pmc.ncbi.nlm.nih.gov/articles/PMC9923792/#:~:text=African%20American%20and%20Hispanic%20Medicare%20beneficiaries%20tend%20to%20have%20lower,et%20al.%2C%202019)." target="_blank">tend to have lower incomes</a>&nbsp;than white beneficiaries, and may by drawn by the lower upfront costs of Medicare Advantage plans.

“[Insurers] like to frame it as, ‘People are choosing us because we’re awesome,’” said Brandon Novick, program outreach assistant at the Center for Economic and Policy Research. “But it’s because financially it makes more sense in the short term” for people with limited incomes.

Meanwhile,&nbsp;<a href="https://www.beckershospitalreview.com/finance/15-health-systems-dropping-medicare-advantage-plans-2024.html" target="_blank">at least 28 health systems</a>&nbsp;in 21 states have stopped accepting some Medicare Advantage plans this year, according to an analysis from Becker’s Hospital Review, an industry publication.

Health systems have cited delayed reimbursements, cumbersome prior authorization requirements and high rates of patient claim denials for their decisions to drop Medicare Advantage plans. Nearly 1 in 5 health systems&nbsp;<a href="https://www.hfma.org/wp-content/uploads/2024/03/Overview-2024-CFO-Pain-Points-Study.pdf" target="_blank">stopped accepting one or more Medicare Advantage plan</a>s last year, according to a report by the Healthcare Financial Management Association.

For retirees like Libby and Andrew Potter, losing access to trusted doctors and hospitals can mean going longer without needed medical care. Finding a new doctor and getting an appointment can take months, particularly for specialists. And for older adults living in rural areas, losing an in-network hospital or physician can mean choosing between a long drive for care or high out-of-pocket costs.

“There are really important access-to-care issues when providers no longer contract with your Medicare Advantage plan,” Trivedi said.

He said the sheer number of plans and differences in benefits might be overwhelming for older adults.

“To sort through all of that when somebody also may have frailty or cognitive impairment, that’s a really tough ask,” Trivedi said. “I study health policy for a living and it’d be hard for me to sort through 40 different options.”

<figure>
 <img src="https://media.eaglewebservices.com/public/2024/10/1729516122048.jpeg" alt="Andrew and Libby Potter look over the letter they received in October, telling them that their region’s largest hospital system would no longer be considered in-network for Libby’s Medicare Advantage policy. The Potters live in Huntsville, Ala., where Libby is a retired middle school librarian and Andrew is a professor at a state university. Anna Claire Vollers/Stateline" />
 <figcaption>Andrew and Libby Potter look over the letter they received in October, telling them that their region’s largest hospital system would no longer be considered in-network for Libby’s Medicare Advantage policy. The Potters live in Huntsville, Ala., where Libby is a retired middle school librarian and Andrew is a professor at a state university. Anna Claire Vollers/Stateline</figcaption>
 </figure><h2>Experts worry older patients could be exposed to ‘catastrophic’ costs and interrupted access to care.</h2>BY:&nbsp;<a href="https://stateline.org/author/avollers/">ANNA CLAIRE VOLLERS</a> <a href="https://stateline.org/">Stateline</a> HUNTSVILLE, Ala. — Libby and Andrew Potter usually ignore the avalanche of Medicare Advantage ads that land in the mailbox at their home in Huntsville, Alabama, each fall as Medicare’s open enrollment period begins.Libby, a retired middle school librarian, has what she considers good health insurance through the state employee health plan. Andrew has insurance through his job as a university professor and plans to join Libby’s insurance when he retires next year.But this year, a few days before open enrollment began, a letter arrived from UnitedHealthcare, informing the Potters that the region’s largest hospital system would no longer be considered in-network for Libby’s Medicare Advantage plan.The Potters spent the next couple of weeks worried and unsure what to do. It seemed incredible that 14 area hospitals, including the area’s only Level 1 trauma center, could suddenly become much, much more expensive.“We were being very careful in how we go up and down stairs,” Libby joked.Medicare is the federal health insurance program for people over 65 and those with certain disabilities. Medicare Advantage is a version of Medicare run by private insurance companies that contract with the government. These plans typically offer extra benefits, such as dental, vision and prescription drug coverage, that aren’t included with traditional Medicare.&nbsp;<a href="https://www.medpac.gov/wp-content/uploads/2024/03/Mar24_Ch12_MedPAC_Report_To_Congress_SEC.pdf" target="_blank">More than half</a>&nbsp;of eligible Medicare beneficiaries now get their coverage through private Medicare Advantage plans.But this year, as Medicare’s open enrollment season kicks off, more than 1 million patients will have to shop for new health insurance. Facing financial and federal regulatory pressures, many insurers are pulling their Medicare Advantage plans from counties and states they’ve deemed unprofitable. Meanwhile, large health systems in states including Alabama, Minnesota and Vermont have cut ties with some Medicare Advantage plans.It’s a situation that’s alarmed state insurance regulators, who are fielding questions from older adults concerned about their hospitals and doctors withdrawing from their Medicare Advantage plans. Last month, the National Association of Insurance Commissioners sent&nbsp;<a href="https://content.naic.org/sites/default/files/inline-files/FINAL%20MA%20SEP%20CMS%20Letter%20Sept%202024.pdf" target="_blank">a letter</a>&nbsp;to the federal Centers for Medicare &amp; Medicaid Services asking for guidance.“Beneficiaries are faced with either paying the increased out-of-network costs or rescheduling their necessary medical services with another provider who may not have prompt availability,” the insurance commissioners’ group wrote. “A delay in access to medically necessary services is likely to result in harm.”The Potters eventually learned that Libby’s copayments at the hospital would remain the same whether or not the hospital was in-network for the state educators’ Medicare Advantage plan. But those with other UnitedHealthcare Medicare Advantage plans will have to pay more — or find another plan.“When a contract leaves the market, that can threaten continuity of care and access to care,” said Dr. Amal Trivedi, professor of health services, policy and practice at the Brown University School of Public Health. “The beneficiary will have to choose a new plan, and each of these plans is going to have a different benefit structure, different provider network, different prior authorization policies and different [prescription drug] formularies.“The worry is that’s going to affect their out-of-pocket costs, expose them to catastrophic spending, or compromise their access to care.”<h2>How we got here</h2>Insurance giants such as UnitedHealthcare have been aggressively pushing enrollment in their Medicaid Advantage plans for the past several years, luring customers with perks and bonuses not available through traditional Medicare. These plans tend to have low or even no monthly premiums and offer extra benefits such as vision and dental coverage, gym memberships, transportation to medical appointments, and even debit cards for medical supplies.And they’re simple: They provide all of a person’s coverage in one plan, unlike traditional Medicare, under which people must get separate prescription drug coverage and supplemental coverage.But there are trade-offs. Medicare Advantage plans often have a limited network of hospitals and physicians. And while the premiums are typically low, enrollees could end up&nbsp;<a href="https://www.ncoa.org/article/what-is-the-difference-between-medicare-advantage-and-medigap/#:~:text=You%20could%20end,with%20Original%20Medicare)." target="_blank">paying more in the long run</a>&nbsp;in copays and deductibles if they develop a serious illness.Medicare Advantage programs also are&nbsp;<a href="https://www.kff.org/medicare/issue-brief/use-of-prior-authorization-in-medicare-advantage-exceeded-46-million-requests-in-2022/#:~:text=Virtually%20all%20enrollees%20in%20Medicare%20Advantage%20(99%25)%20are%20required%20to%20obtain%20prior%20authorization%20for%20some%20services%20%E2%80%93%20most%20commonly%2C%20higher%20cost%20services%2C%20such%20as%20inpatient%20hospital%20stays%2C%20skilled%20nursing%20facility%20stays%2C%20and%20chemotherapy.%20This%20contrasts%20with%20traditional%20Medicare" target="_blank">more likely than traditional Medicare</a>&nbsp;to require prior authorization for hospital stays and other high-cost services. The plans’ prior authorization requirements have&nbsp;<a href="https://www.nytimes.com/2024/05/25/science/medicare-seniors-authorization.html" target="_blank">prompted increased scrutiny</a>&nbsp;in recent years. A congressional investigation by Democratic Senate staff released this month, for example, found the nation’s largest Medicare Advantage insurers&nbsp;<a href="https://www.hsgac.senate.gov/wp-content/uploads/2024.10.17-PSI-Majority-Staff-Report-on-Medicare-Advantage.pdf" target="_blank">denied a quarter of all prior authorization requests</a>&nbsp;for post-acute care in nursing homes, rehab hospitals and long-term care.Medicare Advantage is popular among large employers, many of which are&nbsp;<a href="https://www.kff.org/medicare/issue-brief/10-reasons-why-medicare-advantage-enrollment-is-growing-and-why-it-matters/#:~:text=A%20growing%20share%20of%20large%20employers%20are%20shifting%20their%20Medicare%2Dage%20retirees%20into%20Medicare%20Advantage%20plans%20for%20both%20Medicare%20and%20supplemental%20benefits" target="_blank">shifting their Medicare-age retirees</a>&nbsp;into these plans. And&nbsp;<a href="https://www.kff.org/medicare/issue-brief/in-2024-a-majority-of-states-offer-medicare-advantage-plans-to-their-state-retirees-with-13-offering-medicare-advantage-exclusively/" target="_blank">most states</a>&nbsp;offer Medicare Advantage plans to retired state employees; in 13 states, it’s the only option. In some of those 13 states, retirees forfeit their health benefits in perpetuity if they choose coverage under traditional Medicare.North Carolina Treasurer Dale Folwell, whose office administers the state health plan, said its Medicare Advantage plan is popular.“What we hear from our retirees, is that they are grateful and happy to have such a great offering as a result of their retirement benefit,” the Republican said. “That’s why nearly 89% of our retirees over age 65 have availed themselves of the [Medicare Advantage] product we offer them.”<h2>Insurers retreat</h2>This year, the handful of insurance giants that dominate the Medicare Advantage market have said they’re scaling back or eliminating plans, to shed members and boost sagging profits. They&nbsp;<a href="https://s2.q4cdn.com/447711729/files/doc_financials/2024/q1/CVS-1Q24-Earnings-Transcript.pdf" target="_blank">blame</a>&nbsp;new federal changes to their reimbursements, including&nbsp;<a href="https://www.axios.com/2024/04/02/medicare-advantage-insurer-pay" target="_blank">a small cut to their base payments</a>, and say patients are using more medical services and benefits than they anticipated.Though most companies haven’t released data on specific counties where they’re making cuts, plans are reportedly shuttering in states such as&nbsp;<a href="https://pfsinsurance.com/news/wellcare-080524" target="_blank">Alabama</a>,&nbsp;<a href="https://pfsinsurance.com/news/wellcare-080524" target="_blank">Massachusetts</a>,&nbsp;<a href="https://www.beckerspayer.com/payer/bcbs-kansas-city-exiting-medicare-advantage-market.html" target="_blank">Missouri</a>,&nbsp;<a href="https://www.concordmonitor.com/harvard-pilgrim-medicare-new-hampshire-57353658" target="_blank">New Hampshire</a>,&nbsp;<a href="https://pfsinsurance.com/news/wellcare-080524" target="_blank">New Mexico</a>,&nbsp;<a href="https://www.dmagazine.com/healthcare-business/2024/09/southwestern-health-resources-to-sunset-medicare-advantage-health-plan-amid-layoffs/" target="_blank">Texas</a>&nbsp;and&nbsp;<a href="https://vtdigger.org/2024/10/03/2-medicare-advantage-plans-will-no-longer-be-available-in-vermont-in-2025/" target="_blank">Vermont</a>, affecting hundreds of thousands of older adults. Experts say the reasons why a company might find certain markets unprofitable are complex, but can include demographics, availability of providers and plans that are already in the market.“[T]he industry broadly is going to be trimming benefits and in some cases significantly, and exiting from certain counties that aren’t profitable,” Aetna’s former President Brian Kane&nbsp;<a href="https://s2.q4cdn.com/447711729/files/doc_financials/2024/q1/CVS-1Q24-Earnings-Transcript.pdf" target="_blank">told shareholders</a>&nbsp;on an earnings call in May, before he left his position. Aetna, a subsidiary of CVS Health, is the third-largest Medicare Advantage insurer in the nation. “I think that’s an industry issue and I think it’s clearly an Aetna focus as well.”Executives at CVS Health, Aetna’s parent company, told shareholders the priority for its Medicare Advantage program would be improving profit margins rather than increasing the number of enrollees.They have not announced publicly which counties will lose Medicare Advantage plans, but noted their changes could&nbsp;<a href="https://www.statnews.com/2024/05/14/cvs-aetna-medicare-advantage-cut-benefits/?utm_campaign=health_care_inc&amp;utm_medium=email&amp;_hsenc=p2ANqtz-_KG6jNdcCYt_b2-JXr0SMQbogbV_XDMgmCvnUjnWW5m_UsBvalMlvUPozxIsPXvn9C126pFPAlA2qO2jZszULKf47ccg&amp;_hsmi=307746331&amp;utm_content=307746331&amp;utm_source=hs_email" target="_blank">push out 10% of their membership</a>, meaning up to 420,000 patients could be forced to shop for a different plan.<h2>Canceled plans</h2>Even with the decline in the number of plans available next year, “there are still a lot of plans and people have a lot of options,” said Jeannie Fuglesten Biniek, associate director of the Medicare policy program at KFF, a health policy research organization. Next year, the average Medicare beneficiary will have access to 34 Medicare Advantage plans that include drug coverage, down from 36 this year, she said.But that average masks wide variation across states and even counties in how many plans are available.“There are a handful of counties, more than in previous years, where all Medicare Advantage plans exited and those look to be predominantly rural counties,” said Fuglesten Biniek. “We’re talking fortyish counties out of 3,000. For those people in those counties, that matters, but overall, it’s a smaller number.”Experts say there isn’t enough data available yet to know whether the plan exits are concentrated in certain states or counties.But research has shown that Medicare Advantage plans that enroll higher shares of Black beneficiaries are&nbsp;<a href="https://jamanetwork.com/journals/jama-health-forum/fullarticle/2797677#:~:text=enrolled%20a%20greater%20proportion%20of%20Black%20(21.9%25%20vs%2014.3%25%2C%20P%E2%80%89%3C%E2%80%89.001)%20beneficiaries" target="_blank">more likely to be terminated</a>, said Trivedi, of Brown University. Black enrollees have&nbsp;<a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/1475-6773.13977" target="_blank">more lower-quality Medicare Advantage plans</a>&nbsp;available in their counties of residence than white enrollees, research shows; terminated contracts tend to&nbsp;<a href="https://jamanetwork.com/journals/jama-health-forum/fullarticle/2797677#:~:text=Terminated%20contracts%20tended%20to%20have%20lower%20quality" target="_blank">have lower-quality ratings</a>.“The consequence is that contract terminations in Medicare Advantage seem to have a disproportionate effect on Black beneficiaries because their contracts are more likely to be terminated,” Trivedi said.A&nbsp;<a href="https://www.kff.org/medicare/report/disparities-in-health-measures-by-race-and-ethnicity-among-beneficiaries-in-medicare-advantage-a-review-of-the-literature/" target="_blank">disproportionate share</a>&nbsp;of Medicare Advantage beneficiaries are Black, Hispanic, and Asian and Pacific Islander. These patients&nbsp;<a href="https://pmc.ncbi.nlm.nih.gov/articles/PMC9923792/#:~:text=African%20American%20and%20Hispanic%20Medicare%20beneficiaries%20tend%20to%20have%20lower,et%20al.%2C%202019)." target="_blank">tend to have lower incomes</a>&nbsp;than white beneficiaries, and may by drawn by the lower upfront costs of Medicare Advantage plans.“[Insurers] like to frame it as, ‘People are choosing us because we’re awesome,’” said Brandon Novick, program outreach assistant at the Center for Economic and Policy Research. “But it’s because financially it makes more sense in the short term” for people with limited incomes.Meanwhile,&nbsp;<a href="https://www.beckershospitalreview.com/finance/15-health-systems-dropping-medicare-advantage-plans-2024.html" target="_blank">at least 28 health systems</a>&nbsp;in 21 states have stopped accepting some Medicare Advantage plans this year, according to an analysis from Becker’s Hospital Review, an industry publication.Health systems have cited delayed reimbursements, cumbersome prior authorization requirements and high rates of patient claim denials for their decisions to drop Medicare Advantage plans. Nearly 1 in 5 health systems&nbsp;<a href="https://www.hfma.org/wp-content/uploads/2024/03/Overview-2024-CFO-Pain-Points-Study.pdf" target="_blank">stopped accepting one or more Medicare Advantage plan</a>s last year, according to a report by the Healthcare Financial Management Association.<h2>‘A tough ask’</h2>For retirees like Libby and Andrew Potter, losing access to trusted doctors and hospitals can mean going longer without needed medical care. Finding a new doctor and getting an appointment can take months, particularly for specialists. And for older adults living in rural areas, losing an in-network hospital or physician can mean choosing between a long drive for care or high out-of-pocket costs.“There are really important access-to-care issues when providers no longer contract with your Medicare Advantage plan,” Trivedi said.He said the sheer number of plans and differences in benefits might be overwhelming for older adults.“To sort through all of that when somebody also may have frailty or cognitive impairment, that’s a really tough ask,” Trivedi said. “I study health policy for a living and it’d be hard for me to sort through 40 different options.”

1 million+ patients lose coverage as insurers, hospitals drop Medicare Advantage

WASHINGTON (AP) — A child psychiatrist who altered a first-day-of-school photo he saw on Facebook to make a group of girls appear nude. A U.S. Army soldier accused of creating images depicting children he knew being sexually abused. A software engineer charged with generating hyper-realistic sexually explicit images of children.

Law enforcement agencies across the U.S. are cracking down on a&nbsp;<a href="https://apnews.com/article/ai-artificial-intelligence-child-sexual-abuse-c8f17de56d41f05f55286eb6177138d2">troubling spread of child sexual abuse imagery</a>&nbsp;created through artificial intelligence technology — from manipulated photos of real children to graphic depictions of computer-generated kids. Justice Department officials say they're aggressively going after offenders who exploit AI tools, while&nbsp;<a href="https://apnews.com/article/south-dakota-xylazine-deepfakes-crime-marty-jackley-4167be99dfb79861835a5190472d61b3">states are racing</a>&nbsp;to ensure people generating “deepfakes” and other harmful imagery of kids can be prosecuted under their laws.

“We’ve got to signal early and often that it is a crime, that it will be investigated and prosecuted when the evidence supports it,” Steven Grocki, who leads the Justice Department's Child Exploitation and Obscenity Section, said in an interview with The Associated Press. “And if you’re sitting there thinking otherwise, you fundamentally are wrong. And it’s only a matter of time before somebody holds you accountable.”

The Justice Department says existing federal laws clearly apply to such content, and recently brought what’s believed to be the first federal case involving purely AI-generated imagery — meaning the children depicted are not real but virtual. In another case, federal authorities in August arrested a U.S. soldier stationed in Alaska accused of running innocent pictures of real children he knew through an AI chatbot to make the images sexually explicit.

The prosecutions come as child advocates are urgently working to curb the misuse of technology to prevent a flood of disturbing images officials fear could make it harder to rescue real victims. Law enforcement officials worry investigators will waste time and resources trying to identify and track down exploited children who don’t really exist.

Lawmakers, meanwhile, are passing a flurry of legislation to ensure local prosecutors can bring charges under state laws for AI-generated “deepfakes” and other sexually explicit images of kids. Governors in more than a dozen states have signed laws this year cracking down on digitally created or altered child sexual abuse imagery, according to a review by The National Center for Missing &amp; Exploited Children.

“We’re playing catch-up as law enforcement to a technology that, frankly, is moving far faster than we are," said Ventura County, California District Attorney Erik Nasarenko.

Nasarenko pushed legislation&nbsp;<a href="https://apnews.com/article/ai-deepfakes-children-abuse-7dcf5c566e2a297567f1e148ac2074a4">signed last month</a>&nbsp;by Gov. Gavin Newsom which makes clear that AI-generated child sexual abuse material is illegal under California law. Nasarenko said his office could not prosecute eight cases involving AI-generated content between last December and mid-September because California's law had required prosecutors to prove the imagery depicted a real child.

AI-generated child sexual abuse images can be used to groom children, law enforcement officials say. And even if they aren’t physically abused, kids can be deeply impacted when their image is morphed to appear sexually explicit.

“I felt like a part of me had been taken away. Even though I was not physically violated,” said 17-year-old Kaylin Hayman, who starred on the Disney Channel show “Just Roll with It” and helped push the California bill after she became a victim of “deepfake” imagery.

Hayman testified last year at the federal trial of the man who digitally superimposed her face and those of other child actors onto bodies performing sex acts. He was sentenced in May to more than 14 years in prison.

Open-source AI-models that users can download on their computers are known to be favored by offenders, who can further train or modify the tools to churn out explicit depictions of children, experts say. Abusers trade tips in dark web communities about how to manipulate AI tools to create such content, officials say.

<a href="https://apnews.com/article/generative-ai-illegal-images-child-abuse-3081a81fa79e2a39b67c11201cfd085f">A report last year</a>&nbsp;by the Stanford Internet Observatory found that a research dataset that was the source for leading AI image-makers such as Stable Diffusion contained links to sexually explicit images of kids, contributing to the ease with which some tools have been able to produce harmful imagery. The dataset was taken down, and researchers later said&nbsp;<a href="https://apnews.com/article/ai-image-generators-child-sexual-abuse-laion-stable-diffusion-2652b0f4245fb28ced1cf74c60a8d9f0">they deleted</a>&nbsp;more than 2,000 weblinks to suspected child sexual abuse imagery from it.

Top technology companies, including Google, OpenAI and Stability AI, have agreed to work with anti-child sexual abuse organization Thorn&nbsp;<a href="https://www.thorn.org/blog/generative-ai-principles/">to combat the spread</a>&nbsp;of child sexual abuse images.

But experts say more should have been done at the outset to prevent misuse before the technology became widely available. And steps companies are taking now to make it harder to abuse future versions of AI tools "will do little to prevent" offenders from running older versions of models on their computer “without detection," a Justice Department prosecutor noted in recent court papers.

“Time was not spent on making the products safe, as opposed to efficient, and it's very hard to do after the fact — as we’ve seen,” said David Thiel, the Stanford Internet Observatory's chief technologist.

The National Center for Missing &amp; Exploited Children's CyberTipline last year received about 4,700 reports of content involving AI technology — a small fraction of the more than 36 million total reports of suspected child sexual exploitation. By October of this year, the group was fielding about 450 reports per month of AI-involved content, said Yiota Souras, the group’s chief legal officer.

Those numbers may be an undercount, however, as the images are so realistic it's often difficult to tell whether they were AI-generated, experts say.

“Investigators are spending hours just trying to determine if an image actually depicts a real minor or if it’s AI-generated,” said Rikole Kelly, deputy Ventura County district attorney, who helped write the California bill. “It used to be that there were some really clear indicators ... with the advances in AI technology, that’s just not the case anymore.”

Justice Department officials say they already have the tools under federal law to go after offenders for such imagery.

The U.S. Supreme Court in&nbsp;<a href="https://www.heraldnet.com/news/supreme-court-strikes-down-ban-on-virtual-child-pornography/">2002 struck down a federal ban</a>&nbsp;on virtual child sexual abuse material. But a federal law signed the following year bans the production of visual depictions, including drawings, of children engaged in sexually explicit conduct that are deemed “obscene.” That law, which the Justice Department says has been used in the past to charge cartoon imagery of child sexual abuse, specifically notes there's no requirement “that the minor depicted actually exist.”

The Justice Department brought that charge in May against a Wisconsin software engineer accused of using AI tool Stable Diffusion to create photorealistic images of children engaged in sexually explicit conduct, and was caught after he sent some to a 15-year-old boy through a direct message on Instagram, authorities say. The man's lawyer, who is pushing to dismiss the charges on First Amendment grounds, declined further comment on the allegations in an email to the AP.

A spokesperson for Stability AI said that man is accused of using an earlier version of the tool that was released by another company, Runway ML. Stability AI says that it has “invested in proactive features to prevent the misuse of AI for the production of harmful content” since taking over the exclusive development of the models. A spokesperson for Runway ML didn't immediately respond to a request for comment from the AP.

In cases involving “deepfakes,” when a real child's photo has been digitally altered to make them sexually explicit, the Justice Department is bringing charges under the federal “child pornography" law. In one case, a North Carolina child psychiatrist who used an AI application to digitally “undress” girls posing on the first day of school in a decades-old photo shared on Facebook was convicted of federal charges last year.

WASHINGTON (AP) — A child psychiatrist who altered a first-day-of-school photo he saw on Facebook to make a group of girls appear nude. A U.S. Army soldier accused of creating images depicting children he knew being sexually abused. A software engineer charged with generating hyper-realistic sexually explicit images of children.Law enforcement agencies across the U.S. are cracking down on a&nbsp;<a href="https://apnews.com/article/ai-artificial-intelligence-child-sexual-abuse-c8f17de56d41f05f55286eb6177138d2">troubling spread of child sexual abuse imagery</a>&nbsp;created through artificial intelligence technology — from manipulated photos of real children to graphic depictions of computer-generated kids. Justice Department officials say they're aggressively going after offenders who exploit AI tools, while&nbsp;<a href="https://apnews.com/article/south-dakota-xylazine-deepfakes-crime-marty-jackley-4167be99dfb79861835a5190472d61b3">states are racing</a>&nbsp;to ensure people generating “deepfakes” and other harmful imagery of kids can be prosecuted under their laws.“We’ve got to signal early and often that it is a crime, that it will be investigated and prosecuted when the evidence supports it,” Steven Grocki, who leads the Justice Department's Child Exploitation and Obscenity Section, said in an interview with The Associated Press. “And if you’re sitting there thinking otherwise, you fundamentally are wrong. And it’s only a matter of time before somebody holds you accountable.”The Justice Department says existing federal laws clearly apply to such content, and recently brought what’s believed to be the first federal case involving purely AI-generated imagery — meaning the children depicted are not real but virtual. In another case, federal authorities in August arrested a U.S. soldier stationed in Alaska accused of running innocent pictures of real children he knew through an AI chatbot to make the images sexually explicit.<h2>Trying to catch up to technology</h2>The prosecutions come as child advocates are urgently working to curb the misuse of technology to prevent a flood of disturbing images officials fear could make it harder to rescue real victims. Law enforcement officials worry investigators will waste time and resources trying to identify and track down exploited children who don’t really exist.Lawmakers, meanwhile, are passing a flurry of legislation to ensure local prosecutors can bring charges under state laws for AI-generated “deepfakes” and other sexually explicit images of kids. Governors in more than a dozen states have signed laws this year cracking down on digitally created or altered child sexual abuse imagery, according to a review by The National Center for Missing &amp; Exploited Children.“We’re playing catch-up as law enforcement to a technology that, frankly, is moving far faster than we are," said Ventura County, California District Attorney Erik Nasarenko.Nasarenko pushed legislation&nbsp;<a href="https://apnews.com/article/ai-deepfakes-children-abuse-7dcf5c566e2a297567f1e148ac2074a4">signed last month</a>&nbsp;by Gov. Gavin Newsom which makes clear that AI-generated child sexual abuse material is illegal under California law. Nasarenko said his office could not prosecute eight cases involving AI-generated content between last December and mid-September because California's law had required prosecutors to prove the imagery depicted a real child.AI-generated child sexual abuse images can be used to groom children, law enforcement officials say. And even if they aren’t physically abused, kids can be deeply impacted when their image is morphed to appear sexually explicit.“I felt like a part of me had been taken away. Even though I was not physically violated,” said 17-year-old Kaylin Hayman, who starred on the Disney Channel show “Just Roll with It” and helped push the California bill after she became a victim of “deepfake” imagery.Hayman testified last year at the federal trial of the man who digitally superimposed her face and those of other child actors onto bodies performing sex acts. He was sentenced in May to more than 14 years in prison.Open-source AI-models that users can download on their computers are known to be favored by offenders, who can further train or modify the tools to churn out explicit depictions of children, experts say. Abusers trade tips in dark web communities about how to manipulate AI tools to create such content, officials say.<a href="https://apnews.com/article/generative-ai-illegal-images-child-abuse-3081a81fa79e2a39b67c11201cfd085f">A report last year</a>&nbsp;by the Stanford Internet Observatory found that a research dataset that was the source for leading AI image-makers such as Stable Diffusion contained links to sexually explicit images of kids, contributing to the ease with which some tools have been able to produce harmful imagery. The dataset was taken down, and researchers later said&nbsp;<a href="https://apnews.com/article/ai-image-generators-child-sexual-abuse-laion-stable-diffusion-2652b0f4245fb28ced1cf74c60a8d9f0">they deleted</a>&nbsp;more than 2,000 weblinks to suspected child sexual abuse imagery from it.Top technology companies, including Google, OpenAI and Stability AI, have agreed to work with anti-child sexual abuse organization Thorn&nbsp;<a href="https://www.thorn.org/blog/generative-ai-principles/">to combat the spread</a>&nbsp;of child sexual abuse images.But experts say more should have been done at the outset to prevent misuse before the technology became widely available. And steps companies are taking now to make it harder to abuse future versions of AI tools "will do little to prevent" offenders from running older versions of models on their computer “without detection," a Justice Department prosecutor noted in recent court papers.“Time was not spent on making the products safe, as opposed to efficient, and it's very hard to do after the fact — as we’ve seen,” said David Thiel, the Stanford Internet Observatory's chief technologist.<h2>AI images get more realistic</h2>The National Center for Missing &amp; Exploited Children's CyberTipline last year received about 4,700 reports of content involving AI technology — a small fraction of the more than 36 million total reports of suspected child sexual exploitation. By October of this year, the group was fielding about 450 reports per month of AI-involved content, said Yiota Souras, the group’s chief legal officer.Those numbers may be an undercount, however, as the images are so realistic it's often difficult to tell whether they were AI-generated, experts say.“Investigators are spending hours just trying to determine if an image actually depicts a real minor or if it’s AI-generated,” said Rikole Kelly, deputy Ventura County district attorney, who helped write the California bill. “It used to be that there were some really clear indicators ... with the advances in AI technology, that’s just not the case anymore.”Justice Department officials say they already have the tools under federal law to go after offenders for such imagery.The U.S. Supreme Court in&nbsp;<a href="https://www.heraldnet.com/news/supreme-court-strikes-down-ban-on-virtual-child-pornography/">2002 struck down a federal ban</a>&nbsp;on virtual child sexual abuse material. But a federal law signed the following year bans the production of visual depictions, including drawings, of children engaged in sexually explicit conduct that are deemed “obscene.” That law, which the Justice Department says has been used in the past to charge cartoon imagery of child sexual abuse, specifically notes there's no requirement “that the minor depicted actually exist.”The Justice Department brought that charge in May against a Wisconsin software engineer accused of using AI tool Stable Diffusion to create photorealistic images of children engaged in sexually explicit conduct, and was caught after he sent some to a 15-year-old boy through a direct message on Instagram, authorities say. The man's lawyer, who is pushing to dismiss the charges on First Amendment grounds, declined further comment on the allegations in an email to the AP.A spokesperson for Stability AI said that man is accused of using an earlier version of the tool that was released by another company, Runway ML. Stability AI says that it has “invested in proactive features to prevent the misuse of AI for the production of harmful content” since taking over the exclusive development of the models. A spokesperson for Runway ML didn't immediately respond to a request for comment from the AP.In cases involving “deepfakes,” when a real child's photo has been digitally altered to make them sexually explicit, the Justice Department is bringing charges under the federal “child pornography" law. In one case, a North Carolina child psychiatrist who used an AI application to digitally “undress” girls posing on the first day of school in a decades-old photo shared on Facebook was convicted of federal charges last year.

AI-generated child sexual abuse images are spreading. Law enforcement is racing to stop them

VATICAN CITY (AP) — Pope Francis' yearslong process to&nbsp;<a href="https://apnews.com/article/vatican-pope-reform-women-lgbtq-f8b42b57dcf7ef77dbd3f406780217ed">reform the Catholic Church</a>&nbsp;closed Saturday with recommendations that fell short of giving women more equity as hoped, but reflected the pope’s aims for a church that at least listens more to its followers.

In a significant move, the pope said he would not issue a teaching document from the recommendations, which called for women to be allowed all opportunities that Church law already provides while leaving open the contentious question of permitting women to be ordained as deacons.

As a result, it remains unclear what if any authority or impact the synod’s final recommendations will have, given the purpose of the exercise was to provide the pope with specific proposals on reform.

“In this time of war, we must be witnesses to peace” and give an example of living with differences, the pope said in explaining his decision.

Francis said he would continue to listen to the bishops' counsel, adding “this is not a classic way of endlessly delaying decisions."

Deacons perform many of the same functions as priests, such as presiding over baptisms, weddings and funerals, but they cannot celebrate Mass. Advocates say allowing women to be deacons would help offset the shortage of priests. Opponents say it would signal the start of a slippery slope toward ordaining women to the all-male priesthood that Francis has repeatedly reaffirmed.

Earlier this week, the Vatican's top doctrinal officer, Cardinal Victor Manuel Fernandez, told the extraordinary assembly of 368 bishops and laypeople — including women — that Francis had said the moment “is not ripe” for allowing ordination of women as deacons. He did not respond directly to a request to define what would determine “ripeness” for a greater role for women.

<figure>
 <img src="https://media.eaglewebservices.com/public/2024/6/1718390317432.png" alt="File photo Pope Francis courtesy CSPAN" />
 <figcaption>File photo Pope Francis courtesy CSPAN</figcaption>
 </figure>VATICAN CITY (AP) — Pope Francis' yearslong process to&nbsp;<a href="https://apnews.com/article/vatican-pope-reform-women-lgbtq-f8b42b57dcf7ef77dbd3f406780217ed">reform the Catholic Church</a>&nbsp;closed Saturday with recommendations that fell short of giving women more equity as hoped, but reflected the pope’s aims for a church that at least listens more to its followers.In a significant move, the pope said he would not issue a teaching document from the recommendations, which called for women to be allowed all opportunities that Church law already provides while leaving open the contentious question of permitting women to be ordained as deacons.As a result, it remains unclear what if any authority or impact the synod’s final recommendations will have, given the purpose of the exercise was to provide the pope with specific proposals on reform.“In this time of war, we must be witnesses to peace” and give an example of living with differences, the pope said in explaining his decision.Francis said he would continue to listen to the bishops' counsel, adding “this is not a classic way of endlessly delaying decisions."Deacons perform many of the same functions as priests, such as presiding over baptisms, weddings and funerals, but they cannot celebrate Mass. Advocates say allowing women to be deacons would help offset the shortage of priests. Opponents say it would signal the start of a slippery slope toward ordaining women to the all-male priesthood that Francis has repeatedly reaffirmed.Earlier this week, the Vatican's top doctrinal officer, Cardinal Victor Manuel Fernandez, told the extraordinary assembly of 368 bishops and laypeople — including women — that Francis had said the moment “is not ripe” for allowing ordination of women as deacons. He did not respond directly to a request to define what would determine “ripeness” for a greater role for women.The multi-year synod process had sparked great hopes for change, especially for women, who have long complained that they are treated as second-class citizens in the church. Women are barred from the church's highest ministerial positions, yet do the lion’s share of the work running Catholic hospitals and schools and passing the faith onto future generations.Speaking to the synod on Thursday, Fernandez explained that a special working group would continue beyond the closing of the meeting, but that its focus would be on discussing the&nbsp;<a href="https://apnews.com/article/vatican-reform-women-synod-catholic-church-a6131cb8409f5bc91411f35b493652de">role of women in the church</a>&nbsp;— not in the diaconate, or the office of deacon. He added that while working with women in previous pastoral roles, “most did not ask for or want the diaconate, which would be cumbersome for their lay work.”The meeting asked for “full implementation of all the opportunities already provided for in Canon Law with regard to the role of women, particularly in those places where they remain under-explored.” It leaves open “the question of women's access to diaconal ministry.”It was the most contested paragraph of the final document, with 258 votes for and 97 against. It was not clear if the “no” votes were because the language went too far or not far enough.Phyllis Zagano, a leading scholar on women deacons, said the "no” votes could indicate it is time for a decision to be made.The outcome is a disappointment for Catholics who have been campaigning for recognition that women share a spiritual calling that is no different than a man’s. They also noted that despite the inclusion of women in the synodal process, the working group that is guiding discussions on women’s role is being run by the Roman curia, operating outside the synod.“I think the final document will be received with much disappointment and frustration by many women around the world who are hoping for concrete changes,'' said Kate McElwee, the executive director of the Women’s Ordination Conference.While she acknowledged a “cultural shift,” she said "the pace of that shift is perhaps too slow for many women.”Gay rights activists also expressed disappointment, noting the failure to include LGBTQ+ issues in the final documents. “The laity of the church must now become louder and more vigorous than ever in advocating for reform,'' said Francis DeBernardo, executive director of New Ways Ministry.The&nbsp;<a href="https://apnews.com/article/vatican-women-synod-pope-bfe024ad3234a9511738b9fd5c598ef7">first phase of the synod process</a>&nbsp;ended last year by concluding it was “urgent” to guarantee fuller participation by women in church governance positions, and calling for theological and pastoral research to continue about allowing women to be deacons.If before the synod the idea of allowing women to be deacons was a fringe proposal pushed by Western progressives, the idea gained attention during the debate. It became something of a litmus test of how far the church was going to go, or not, to address demands of women for greater equality and representation in the church's highest ranks.