imageBy Nell Greenfieldboyce • 16 hours ago The International Space Station is reflected in the visor of Expedition 59 Flight Engineer David Saint-Jacques of the Canadian Space Agency. NASA Listening… /
When a rocket carrying the first module of the International Space Station blasted off from Kazakhstan in November of 1998, NASA officials said that the station would serve as an orbiting home for astronauts and cosmonauts for at least 15 years.
It’s now been over 18 years that the station has been continuously occupied by people. The place is impressive, with more living space than a six-bedroom house, two bathrooms and a large bay window for looking down at Earth.
NASA and its international partners have spent decades and more than $100 billion to make the station a reality.

The trouble is, as the agency sets its sights on returning people to the moon, the aging station has become a financial burden. And it’s not clear what its future holds.

The ISS photographed from the space shuttle Atlantis after the station and shuttle began their post-undocking relative separation on May 23, 2010. NASA
NASA spends between $3 billion and $4 billion a year operating the station and flying people back and forth. That’s about half the agency’s budget for human exploration of space.
The United States and the other participating nations have pledged to fund the station until at least 2024, but it will surely last longer than that.

Gilles Leclerc , head of space exploration at the Canadian Space Agency, says there’s no way that the international partners would come together in five years and decide to just crash the station into the ocean to so that resources could be directed to other space goals.
“It would be a waste.

We cannot ditch the International Space Station.

There’s just too much invested,” says Leclerc.

“It’s quite clear, it’s unanimous between the partners that we continue to need a space station in low Earth orbit.”
So NASA has floated one money-saving idea: turn the space station over to the private sector. That’s why, a few weeks ago, NASA officials held a big press event at the Nasdaq stock market’s MarketSite in New York City.
“NASA is opening the international space station to commercial opportunities and marketing these opportunities as we’ve never done before,” said the agency’s chief financial officer, Jeff DeWit .

“The commercialization of low Earth orbit will enable NASA to focus resources to land the first woman and next man on the moon by 2024, as the first phase in creating a sustainable lunar presence to prepare for future missions to Mars.”
Astronaut Christina Koch appeared in video beamed down from space. “We are so excited to be part of NASA as our home and laboratory in space transitions to into being accessible to expanded commercial and marketing opportunities, as well as to private astronauts,” she said. Expedition 59 Flight, engineers Anne McClain of NASA (red stripes) and David Saint-Jacques of the Canadian Space Agency are seen while working outside the International Space Station in April.

All this produced a sense of déjà vu in John Logsdon , a space historian with George Washington University. Back in the 1980s, when Ronald Reagan’s administration first proposed building a permanent space station, part of the pitch was “the idea that it could be a place for a wide variety of commercial activities, with billions of dollars of economic payoff,” says Logsdon. “So here we are in 2019, finally going to test that hypothesis.”
When reporters asked how much revenue could come in from new commercial activities on the station, however, NASA officials wouldn’t give any numbers, saying there was too much uncertainty.

“The 12 industry studies NASA commissioned last year estimated revenue projections for future low-Earth orbit destinations across a variety of markets, and those projections varied significantly as a result of uncertainty associated with these future markets,” a NASA spokesperson told NPR. “The markets and services that will generate revenue need to be cultivated by the creative and entrepreneurial private sector.”
“That is the right answer because they don’t know yet,” says Tommy Sanford , executive director of the Commercial Spaceflight Federation.
But if the space station became commercially-operated or even privately owned, NASA could become just one of many customers.
“You need to be focused on adding as many customers as possible and hoping to reach a tipping point, at some point, where you retain all of them,” says Sanford. “Then that eventually lowers your cost, because you are one of many customers. You aren’t bearing the entire cost of the infrastructure and transportation.

Some question whether any business could make a go of running a space station without the government still ponying up a ton of money.

“Candidly, the scant commercial interest shown in the station over its nearly 20 years of operation give us pause about the agency’s current plans,” NASA Inspector General Paul Martin told members of Congress last year.
As all of these discussions go on, the station keeps getting older. Space is a harsh environment. The hardware is wearing out, and major components are only certified until 2028.

“Space station really has up to, say, less than 10 years of lifetime,” says Dava Newman , a scientist at MIT and a former NASA deputy administrator.
She loves the station and has flown experiments on it. But she thinks with time running out, there needs to be a strategic plan for its end. The uncrewed SpaceX Crew Dragon spacecraft is silhouetted against the Earth’s horizon during Demo-1, the first flight of NASA’s Commercial Crew Program to the International Space Station. The vehicle ultimately docked to the station’s Harmony module after completing several successful demonstrations during approach. NASA
“There might be some elements of space station that the private [sector] might be able to take over, a module or two,” she says. “All of that needs to be put into place, probably with government funding.”
Eventually, big components of the station will have to crash back down to Earth.

Asked when NASA expected to deorbit the station, a spokesperson for the agency said that no specific year is being targeted.
“Transition from the space station will occur once commercial habitable destinations are available and can support NASA’s needs as one of many customers,” the spokesperson said.

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For people living in rural communities, accessing health care can be a challenge. Hospitals have closed. Doctors are in short supply. Advances in technology may help solve some of these problems. Polling by NPR finds that many rural Americans are using and liking technologies that can provide diagnosis and treatment, even when the health-care provider is not in the room with the patient. NPR’s Patti Neighmond reports on the findings of the poll conducted by NPR, the Robert Wood Johnson Foundation and the Harvard T.H.

Chan School of Public Health.
PATTI NEIGHMOND, BYLINE: Beautiful but isolated is how Jill Hill describes where she lives.

Grass Valley’s an old mining town in the Sierra Nevada foothills of Northern California.

Jill gives me a tour of her garden, framed by a fence handmade from pieces of old wooden slats and gnarly tree branches.
JILL HILL: We’ve got kale, lettuce, parsley. We’ll have tomatoes going. And we grow pumpkins and cantaloupe.

NEIGHMOND: Hill’s grown to love it here. But at 63, she never thought her life would be like this.
HILL: We were living in Arizona. My husband was in construction.
NEIGHMOND: A project manager for a multi-million-dollar homebuilding company.
HILL: We had health insurance. We had life insurance.

We had the American dream.

NEIGHMOND: Then the housing crisis hit in 2008. Her husband lost his job and his health insurance. He got sick and ended up on dialysis. They decided to move back to California and rebuild their lives, but her husband passed away a few years later.
HILL: I was grief-stricken. And my self-esteem was down.

I didn’t care about myself. I didn’t brush my hair. I isolated. I just kind of locked myself in the bedroom.
NEIGHMOND: She knew she needed therapy, but the nearby community health center in this rural area had only two therapists. She could see one once a month.

She knew she needed more.
HILL: So then Brandy called me and said, hey.

We’ve got this telehealth program, where they bring the therapist in on a computer screen, like Skype. And do you want to try it?
NEIGHMOND: Brandy Hartsgrove coordinates telehealth for the Chapa-de Indian Health Clinic. Telehealth sounded a bit impersonal to Hill, but she says she was desperate and willing to try it.

HILL: This is my chair.

NEIGHMOND: For almost a year now, Hill’s been sitting in this chair in front of a large computer screen. Twice a week for 30 minutes, she speaks with a clinical psychologist hundreds of miles away in San Diego.

Her latest assignment in therapy; write down her positive characteristics.
HILL: And I had three.
NEIGHMOND: What were they?
HILL: Oh, loyalty, compassion and resilience. She said, only three? She wanted 10. And I said, well, I’m just getting started. Well, then she and I started talking.

And now I’ve got, like, probably 15 at least. And I’m – keep adding to the list. But once I started, like, writing things down, I started really seeing I have a lot of strengths.
NEIGHMOND: Hill says she’s lucky. The Chapa-de clinic offers telehealth. Many clinics don’t, which means people have to rely on their own resources. And in many rural areas, that’s nearly impossible, according to Harvard professor Robert Blendon, who co-directed our poll about life and health among rural Americans.
ROBERT BLENDON: The majority – essentially, 8 in 10 people living in rural America – have access to high-speed Internet.

But 1 in 5 really have a problem having access to it. And that means they don’t have the ability to get critical information in today’s world.

NEIGHMOND: This includes information such as diagnosing a problem, providing treatment or getting medical advice.
BLENDON: They lose the ability to contact their physicians, to fill prescriptions and to get follow-up information without having to go see a health professional.
NEIGHMOND: In our poll, a vast majority of those who were able to use telehealth reported being satisfied with the diagnosis or treatment they received. An important note here – telehealth comes in many forms. It can be a patient speaking directly with a health care provider via text, email or on-screen like Jill Hill. It can also be doctor-to-doctor like it is for critical-care pediatrician James Morrison with the UC Davis Children’s Hospital, where patients often face long, costly trips just to get needed specialty care.

JAMES MARCIN: We have patients that drive to our Sacramento offices that have to drive the night before, spend the night in a hotel because it’s a five-hour trip each way. And if you’re talking about taking time off of work or school, the costs of getting what should be otherwise routine care are significant barriers for those living in rural communities.
NEIGHMOND: Telehealth can remove those barriers, says Marcin, by bringing UC Davis specialists to the patient’s bedside hundreds of miles away.
MARCIN: In the emergency department, they’re able to put the telemedicine cart at the patient’s bedside.

And within minutes, our physicians are able to see the child and talk with the family members and help assist in the care that way.
NEIGHMOND: It’s not just emergency care. It can also be cardiology, gastroenterology, dermatology – any number of specialty services. Attorney Mei Kwong with the Center for Connected Health Policy agrees telehealth holds great potential to reduce disparities.

But she says payment policies for telehealth services lag way behind the technology.
MEI KWONG: A lot of the policies that are out there are probably about 15 to 10 years behind, unlike what the technology can do now.

So stuff that they have on the books regarding telehealth maybe made sense about 10 or 15 years ago because the technology wasn’t at a place where it is today and what it can do and what it can safely do.
NEIGHMOND: For example, services like high-resolution photos, retinal screenings for diabetic patients or consultations between a specialist and primary care doctor may not be paid for by Medicaid, Medicare or private insurance.

Today change is happening, says Kwong, but it’s slow-going.
Patti Neighmond, NPR News.
(SOUNDBITE OF LAKEY INSPIRED’S “5 MIN CALL”) Transcript provided by NPR, Copyright NPR. © 2019 Connecticut Public Radio.

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